
Class _ 

Book___ 
Copyright^ . 



COPYRIGHT DEPOSIT; 




Egyptian Pellagra. 
Courtesy of Dr. F. M. Sandwith. 



PELLAGRA 

BY 

DR. A. MARIE 

Physician to the Asylums, (Department of the Seine, Editor-in-Chief, 

Archives de Neurologie, and 'Director of the Laboratory 

of Pathological Psychology, EcoJe des Hautes 

Etudes, Paris, France 

With Introductory Notes by Prof. Lombroso 

Authorized Translation From the French 
BY 

C. H. LAVINDER, M. D. 

Passed Assistant Surgeon TJ. S. Public Health and 
Tvfarine Hospital Service 

AND 

J. W. BABCOCK, M. D. 

Physician and Superintendent State Hospital for the 
Insane, Columbia, S. C. 

With Additions, Illustrations. Bibliography and Appendices 



1910 

THE STATE CO.. PUBLISHERS 

Columbia. S. C. 



■vV 



•ftV^v 






Copyright, 1910 

by 

The State Company 



©CI.A278029 



TRANSLATORS' PREFACE 

We feel that we need plead no excuse at this time 
for offering the American profession a monograph 
on pellagra. The recent recognition of the preval- 
ence of this serious disease in the United States, its 
importance as a public health problem, and the 
absence of an English treatise upon a subject so 
vital, seem to us ample justification of this effort on 
our part. 

With a full comprehension of the comparatively 
limited experience of ourselves and of all American 
students of this disease, we have deemed it advisable 
to offer a translation, rather than attempt an 
original work. We selected, for such translation, 
Dr. A. Marie's "La Pellagre? Paris, 1908, for the 
reasons that it is recent; that it seemed the most 
suitable work, both in subject-matter and in size; 
that it would lend itself more readily to the adapta- 
tion necessary for the needs of the American physi- 
cian, and, above all, that it is largely an abridgment 
of Professor Lombroso's important work — Trattato 
Profilattico e Clinico delta Pellagra, Turin, 1892 — 
itself too extensive for translation, yet without which 
no present treatise on the malady could be consid- 
ered complete. 

For his generous permission thus to adapt his 
book to our purposes and for many other courtesies, 
we herewith record our profound gratitude to Pro- 
fessor Marie. 

Having been prepared for readers long familiar 
with the subject, and being, as it is, not only a trans- 



4 PELLAGRA 

lation, but likewise an abridgment of Professor 
Lombroso's treatise, Doctor Marie's book presented 
many points too succinctly for American students. 
Moreover, there are in the original French work 
omissions of some features which we have thought 
necessary to supply in the present translation. This 
has required in many places rather extensive addi- 
tions,— liberties to which Doctor Marie has very 
graciously consented. Such additions are shown by 
the conventional use of brackets [ ]. 

We have earnestly striven to deal adequately with 
all these difficulties, and in so doing have not only 
consulted a great many original sources, but we have, 
for the sake of clearness, practically compared, word 
for word, the French text with the original Italian 
of Professor Lombroso. We have also endeavored 
to include the latest opinions regarding the possible 
parasitic origin of pellagra. 

Certain striking phases of the history of the sub- 
ject which could not be included in the body of the 
book, have been inserted as appendices. 

We have compiled an English bibliography upon 
pellagra and have, in addition, listed many of the 
most important foreign contributions to the subject. 
Our obligations to the literature of pellagra are 
hereby acknowledged. 

For the privilege of using certain data and photo- 
graphs we are especially indebted to Surgeon-Gen- 
eral Walter Wyman, U. S. Public Health and 
Marine-Hospital Service, who with prompt compre- 
hension of the importance of pellagra in this country, 
has in many ways stimulated investigations upon 
this new problem. 



For permission to use photographs illustrating 
types of pellagra occurring in different countries and 
for other favors, we are indebted to Dr. F. M. Sand- 
with and Dr. L. W. Sambon, London, England ^ Dr. 
John Warnock and Dr. E. G. White, Abbassia, 
Cairo, Egypt; the late W. Bayard Cutting, Jr., of 
New York, and formerly U. S. Vice-Consul, Milan, 
Italy; Dr. George A. Zeller, Peoria, 111., and Dr. 
J. J. Watson, Columbia, S. C. 

In addition to his friendly interest in our work 
we owe a further debt of gratitude to Professor 
Lombroso for a special preface to this translation, 
which was received only a short time before his 
lamented death. To G. W. Manly, Ph. D., of Colum- 
bia, S. C, we are under many obligations for 
assistance in the translation, in preparing manu- 
script and in seeing the book through the press. 

To the publishers we are thankful not only 
for their unsolicited interest in assuming the respon- 
sibility for the book, but also for their great forbear- 
ance and patience at unavoidable delays. 

Finally, while recognizing its shortcomings we 
earnestly hope that this little book may prove help- 
ful and stimulating both to the clinician and the 
sanitarian in dealing with this important disease. 

The Translators. 

Columbia, S. C, October 1, 1910. 



PREFACE 

By Professor C. Lombroso. 

It is impossible to estimate at once the harm which 
has resulted from the many visionary and obscure 
theories that have been advanced regarding the 
etiology of pellagra. 

Had it been a question of purely theoretic import, 
nothing would have been lost but time and paper 
and perhaps a little of the reputation of those 
authorities who have too often been misled by their 
chimerical plans of salvation. But in combating 
pellagra great sums of money have been misspent 
through the failure to attack the true causative 
factors. 

The most diverse and untenable hypotheses have 
been considered in turn. In former times the sun, 
impure water, insanitary dwellings and even the 
absence of salt were regarded as the real causes. 
The expense incurred on the basis of these Quixotic 
presumptions has been much greater than it would 
have been to attack, at the root, the actual causes of 
the malady. The deception which followed all these 
vain attempts not only retarded but even thwarted 
serious and effective investigation. 

If obstinate antagonism to my theory of pellagra 
has checked, for a time, my scientific career, it has 
at least led to a definite orientation of the research 
work in that direction where I was engaged; 
whereas, otherwise, the blind and ineffective grop- 
ings would have been continued. A phalanx of 
skillful and talented investigators has undertaken 



8 PELLAGRA 

the experimental study of the etiology; others have 
attacked the statistical and agricultural side of the 
question; by profound researches eminent patholo- 
gists have thrown light upon the morbid anatomy; 
therapeutic and hygienic investigations have been 
extensively carried on ; in short, continued opposition 
has impelled me to struggle with the greatest energy 
in order to perfect my clinical knowledge and my 
experimental methods. Furthermore, I have by a 
series of bold, but encouraging experiments, tested 
the. application of my theory by the therapeutics 
of cutaneous diseases, and thus, the theory held by 
me about pellagra has found in a reciprocal way 
(a posteriori) its confirmation. 

Finally, I have sustained as paramount preventive 
measures against pellagra: the drying of Indian 
corn and the exclusion of the spoiled grain. 

Since these methods have been employed upon a 
large scale our hopes have been fully realized ; the 
number of fatal cases of pellagra — the only source 
of statistics which merits confidence — has shown in 
consequence a proportionate reduction. Such a 
result is, indeed, well worth the personal sacrifices 
of an investigator. 

Dr. A. Marie has been desirous of giving in a 
small volume a complete resume of my work and 
of the actual state of the pellagra question.* 

♦Lombroso, C. — 1 Studi clinici ed esperimentali sulla natura, 
causa e terapia della pellagra. Bologna, 1872. 

2 I veleni del mais e la loro applicazione all' igiene ed alia terapia. 
Bologna, 1878. 

8 Trattato profilattico e clinico della pellagra. Turin, 1892 

*Lombroso and Ottolenghi. — L'azione tossica dell' oidium lactis 
nella polenta. 1890. 



PREFACE y 

He has my gratitude for his efforts, and it is my 
wish that this work may make our investigations 
and their happy results better known in France. It 
is likewise my wish that it may facilitate and 
encourage the task of all who have undertaken to 
struggle for the liberation of our race from the social 
poisons which lie in wait under the cover of ignor- 
ance, selfishness and poverty. 

Turin, Italy. 



PREFATORY NOTE TO THE TRANSLATORS. 

I wish duly to comply with your request for a 
brief prelude to the English translation of Doctor 
Marie's compilation of my work by announcing the 
more recent observations made this year, in my 
laboratory, upon the cause and prophylaxis of pel- 
lagra. 

First of all, from the experiments made by Pro- 
fessor von Deckenbach of St. Petersburg, the con- 
clusion has been reached that the culture of oospora 
verticilloides from corn, produces phenomena in 
animals similar to those of pellagra, as was to be 
anticipated, since in Bessarabia when corn is much 
affected with oospora, pellagra is likely to be preva- 
lent. 

Many scientific inquiries are still raised as to the 
possibility that pellagra may originate even from 
sound corn. With Doctor Audenino, I carried out 
a series of experiments upon animals with the result, 
to be sure, that rabbits fed on sound corn died after 
a certain time, but I satisfied myself that our results 
demonstrated the fact that we were dealing, not with 
a poison derived from corn, but with the impossi- 
bility of adapting the food used, a grain, to the 
natural requirements of herbivorous animals. This 
is emphatically proven because feeding with corn, 
but. at the same time, with an abundance of greens 
also, does not cause death in rabbits; and since 
pigeons and chickens, granivorous creatures, can be 
fed on such corn alone without harm. 



12 PELLAGRA 

Finally, I have shown that penicillium and asper- 
gilli of corn are truly pellagrogenous but only when 
growing upon spoiled corn, from which they imbibe 
toxic substances ; while, on the contrary, when grow- 
ing upon other plants or material, which have not 
undergone putrefactive change, they are absolutely 
harmless. 

In conclusion, having observed how one of the 
causes of pellagra arises from the fraudulent 
methods of millers, we have introduced with great 
advantage in pellagra-stricken districts a rapid 
hand-mill (Bamford) which furnishes fresh meal, 
in the necessary quantities for daily use, without 
recourse to the lethal products of the wholesale 
dealers. Here, again, sound Indian corn scores a 
point. This method, I believe, is worthy of trial and 
adoption in America. 

C. Lombroso, 
Professor of Clinical Psychiatry. 

Turin, Sept., 1909. 



CONTENTS. 



Page 

Translators' Preface 3 

Preface 7 

Prefatory Note to Translators 11 

Contents 13 

Illustrations 15 

Chapter I. History and Geography of Pellagra. Rela- 
tion of the Disease to Corn 17 

Chapter II. General Statistics 44 

Chapter III. Study of Spoiled Corn — Its Physical, 
Chemical, Microscopic and Bacteriologic Charac- 
teristics 77 

Chapter IV. Experimental Researches and Etiology . . 93 

Chapter V. Clinical Study of Pellagra 147 

Chapter VI. Generalizations — Chief Forms of Pellagra, 

Signs and Symptoms 182 

Chapter VII. Psychic and Paretic Phenomena, Compli- 
cations, Heredity 235 

Chapter VIII. Pathological Anatomy 261 

Chapter IX. Diagnosis, Prognosis, Prophylaxis and 

Treatment 278 

Chapter X. Corn and Pellagra in France. Roussel and 

Lombroso 314 



14 PELLAGRA 

Page 
Bibliography : 

A. English .351 

B. Foreign 369 

Appendix I. Italian Law of 1902 383 

Appendix II. Regulations for Execution of Law of 

1902 388 

Appendix III. Venetian Proclamation, 1776 .... 396 
Appendix IV. Rules for Avoiding Pellagra .... 401 

Appendix V. Corn Crop, 1907 404 

References 409 

Index 416 






ILLUSTRATIONS 

Egyptian Pellagra Frontispiece 

Dermatitis of arms and chest ("breastplate"). 

Plate I. South Carolina Case. Symmetrical lesions of 

hands. Skin dry and exfoliating. Color 
dark. 

Plate II. Illinois Case. Pellagrous "glove." 

Plate III. Egyptian Case. Dry dermatitis on face, 
hands, neck and upper chest. 

Plate IV. Egyptian Case. Same case as Plate III. 
Pellagrous "mask." 

Plate V. Egyptian Case. Hands of case shown in 

Plate III. Skin much thickened. Der- 
matitis dry and scaling. 

Plate VI. Italian Case. Symmetrical, dry, scaly der- 
matitis of hands and forearms. Charac- 
teristic facial expression. 

Plate VII. South Carolina Case. "Wet" Deimatitis. 
Localization unusual. Hands edematous. 
Cachectic stage. 

Plate VIII. South Carolina Case. Skin of hands dry and 
thickened. Marked seborrhea of nose and 
face. Extreme emaciation of cachectic- 
stage. Death followed in a few days. 

Plate IX. South Carolina Case. Chronic dermatitis 
showing deep fissures. Also dactylitis and 
deformities. Probably a complicated case. 

Plate X. South Carolina Case. Exfoliating dermatitis 

of feet, the lesions being slightly "wet." 



16 PELLAGRA 

Plate XI. South Carolina Case. Dermatitis of face, 
neck, elbows, hands and knees. 

Plate XII. Egyptian Case. Compare with Plate XI. 

Plate XIII. Illinois Case. Pellagrous "gauntlet" and 
unusual localization on arms. 

Plate XIV. Illinois Case. Unusual localization involving 
mastoid and frontal regions; bilateral. 

Plate XV. Illinois Case. Marked symmetry of all 
lesions. 

Plate XVI. South Carolina Case. "Wet" dermatitis of 
face, hands and lips. Note characteristic 
facial expression. 

Plate XVII. South Carolina Case. Same as Plate XVI. 
Convalescent and showing pigmentation of 
hands and arms. 

Plate XVIII. South Carolina Case. "Wet" form. Dermatitis 
of hands, elbows, face, and lips. Super- 
ficial ulceration of hands. 

Plate XIX. South Carolina Case. Wet form. Lesions 
identical with those of Plate XVII 1. Both 
cases under observation at same time and 
both rapidly fatal. 



Chaet I. South Carolina Case. Rather severe. Common 
temperature curve. 

Chabt II. South Carolina Case. "Wet" dermatitis. Varia- 
ble temperature. Development of cachexia. 
Death from exhaustion. 

Chart III. South Carolina Case. Three years' duration. 
Terminal acute delirium with hyperpyrexia. 
Death. 

Chaet IV. South Carolina Case. Dry dermatitis. Ter- 
minal acute delirium. Tetanoid state and rapid 
dissolution. So-called typhoid pellagra. 



CHAPTER I 

History and Geography of Pellagra. — Relation 
of the Disease to Corn. 

"If you should traverse the hills of Brianza and 
Canavese you would most likely meet some pitiable 
wrecks of humanity, with eyes fixed and glassy, with 
pale and sallow faces and arms fissured and scarred 
as by a burn or large wound. You would see them 
advancing with trembling head and staggering gait 
like persons intoxicated or, indeed, as though 
impelled by an invisible force, now falling on one 
side, now getting up and running in a straight line 
like a dog after its quarry and now again falling 
and uttering a senseless laugh or a sob which 
pierces the heart — such are the pellagrins, poisoned 
by the toxins of spoiled Indian corn." [With this 
word picture Lombroso begins his latest and most 
elaborate treatise on pellagra.]* 

Food adulterations belong to all times and fraud- 
ulent methods have been applied to every substance 
capable of nourishing human beings. It is not 
alone the intrinsic value of the materials which 
induces adulteration, but also their extensive con- 
sumption; hence, cereals produced in considerable 
quantities are often, in the course of varied handling, 
subject to sophistication for the purpose of hiding 
their defects. Indian corn is one of the cereals very 
frequently adulterated because in many countries 
its products are in general use as food. 

•Trattato profilattico e clinico della pellagra, Turin, 1892. 



18 PELLAGRA 

Alterations in corn are the cause of pellagra. The 
occurrence of this disease presupposes the general 
use of corn as food. That is to say, the geographical 
distribution of pellagra corresponds to the zone in 
which corn is cultivated and in common use as food. 
But to cause pellagra it is not sufficient merely to use 
corn; it is further necessary that the corn so used 
should be spoiled. The important question, however, 
is, what among the divers changes to which this 
grain is susceptible, are the special ones we should 
incriminate as producing pellagra ? 

After a short historical glance at the problem in a 
general way, we shall proceed to the examination of 
these different questions. First, we shall consider 
the principal countries where pellagra is prevalent 
and the existing statistics with regard thereto. We 
shall next examine into the question, what are the 
conditions most favorable for toxic alterations in 
the grain, including the geographical distribution 
and seasonal appearances of pellagra? Then we 
shall give the results of the most recent microscopic 
investigations of ferments and parasitic moulds 
capable of altering corn and its products. We shall 
next study the clinical manifestations of the intox- 
ication, and particularly its far-reaching complica- 
tions for the individual, often leading to insanity 
and hereditary degeneracy. [Diagnosis, prognosis, 
prophylaxis and treatment will receive due consid- 
eration.] 

Synonyms. — Alpine Scurvy, Asturian Leprosy, 
Asturian Rose, Disease of the Landes, Maidismus, 
Psychoneurosis Maidica, Mai de la Rosa, Mai del 
sole, Mai de Misere, and a great many others. 



HISTORY AND GEOGRAPHY 19 

Definition. — Pellagra is an endemic malady which 
is characterized by an erythema upon the exposed 
surfaces of the body, by gastro-intestinal disorders 
and by nervous phenomena of toxic origin. It may 
terminate by severe cachexia or insanity. 

"Pellagra," says Dechambre, "is a food poisoning 
generally due to the use of spoiled corn, having the 
characteristics of endemicity in the countries where 
spoiled corn is consumed as food, and by epidemicity 
in the years and seasons in which the corn crop is 
most seriously damaged." 

History, Geography and Relation to Corn. — The 
appearance of pellagra in Europe goes back to 1720, 
the epoch of the introduction of corn planting. 

[According to Babes and Sion it is probable that 
pellagra appeared in Europe long before its scientific 
description, but it was classed with such diseases as 
chronic intestinal and nervous conditions or mental 
disorders, or, again, as leprous or scorbutic manifes- 
tations. So it is difficult to determine whether or 
not the disease antedated the introduction of corn 
into Europe. In fact, there is no agreement among 
writers when the latter event took place. The first 
recognition and description of the disease is usually 
credited to Gaspar Casal of Spain, 1735.] 

The authors who claim to have found descriptions 
of this disease in these very regions anterior to this 
date have been deceived. For example, F. Frapolli 
erroneously believed he had found a picture of 
pellagra in the description of la pellarella in 1578, 
when as a matter of fact that condition was a 
syphilitic manifestation. [But to Frapolli we are 



20 PELLAGRA 

indebted for the introduction, in 1771, of the name 
pellagra, which is usually derived from pelle — skin 
and agra — rough. He is said to have found the word 
already in use among the people.] 

The history of the progress of this endemic affec- 
tion, reconstructed according to the successive medical 
descriptions in diverse regions, coincides with that 
of the extension of corn culture or of its importation 
and use. It is sufficient to recapitulate the principal 
works by date, by authors and by localities from 
1760 to 1807. 

1760-1779. Terzaghi, Moscati, Alberti— Upper 
Lombardy. 

1771-1778. Frapolli and Zanetti— Central Lom- 
bardy and Milan. 

1776. Odoardi — Upper Milan and Tessin. 

1780-1786. Ghirlanda Gherardini— Treviso. 

1788-1789. Strambio, Jansen — Central Lom- 
bardy. 

1795. Allioni— Milan. 

1790-1807. Frione — Venice and Corinthia. 

1807. Cerri — Eastern Lombardy. 

The geographical progress of the scourge from the 
center to the north and towards the east can be 
traced in this bibliographic-historic resume. 

Some apparent contradictions may be explained 
by going deeper into the examination. Thus, Greece, 
having already introduced the cultivation of corn, 
was found free from pellagra by Holland (1817) ; 
whereas, some regions to which Greece exported 
corn suffered from the malady. This resulted from 
the fact that the change in the grain necessary to 



HISTORY AND GEOGRAPHY 21 

produce the disease had taken place during trans- 
portation ; that is, from defective loading, rains and 
humidity. 

As we shall see, the seasonal fluctuations of the 
malady in certain countries confirm these views. 
Indeed, we can verify their association, by com- 
paring the official statistics of our time with the 
maps showing corn production, for example, in 
Italy, where the Minister of Agriculture has 
arranged these data in parallel columns. 

In Abruzzi, where they have just begun to use corn 
as food, pellagra has as yet made very little head- 
way; as also in Florence, and in Arezzo especially, 
as well as in Siena, where corn is little used. The 
very provinces where pellagrins are most numer- 
ous are those in which corn products are extensively 
used, as the provinces of Padua, Brescia, Cremona, 
Rovigo, Ferrara, Novara, Lucca, Venetia and Ber- 
gamo. Hence, we can no longer doubt a relation- 
ship between Indian corn and pellagra. 

The counterpart of the above data is found in the 
instances where the cultivation and use of corn 
having been given up, pellagra has disappeared. 
After a philanthropist, Costa, introduced into cer- 
tain localities of Italy the cultivation of lupines, 
which enrich the soil and permit the keeping of a 
larger number of animals, not only did the cultiva- 
tion and importation of corn decline, but pellagra 
also. 

It is interesting to cast a glance at the facts col- 
lected by observers in other countries, which agree 
in a general way with our own. 



22 PELLAGRA 

In Roumania, Felix states that pellagra has 
appeared in consequence of the continued use of 
mouldy corn as food. He incriminates particularly 
Penicillium glaucum, and Puccinia segetum and 
nigricans. 

The Eoumanian peasant recognizes that corn im- 
properly harvested becomes covered with a whitish 
coating, that it has the taste of mould, and that 
soup made from such corn causes thirst and 
indigestion. It often happens, indeed, that it 
has no other consequences. These peasants suffer 
also from intermittent fever. They are badly 
housed and poorly nourished. Many of them 
are unable to sow their corn until very late; 
and they harvest it either too early or during the 
autumnal rains. They gather it then in little woven 
baskets which do not protect it from dampness, so 
that the grain becomes covered with mould and 
often actually decays. Roumanian infants are 
affected by pellagra as well as adults. Antoniu 
and Mcolaidi saw there a great number of little 
children who were pellagrous. The former of these 
authors has studied with especial care the pella- 
grous in the district where he is chief physician. 
He had under observation 500 pellagrins and con- 
sidered Penicillium as the only cause of the malady. 
He reported cases among the well-to-do and robust 
inhabitants of the high regions of the district of 
Piatra who use milk and meat, but who are often 
obliged to harvest their corn before its complete 
maturity. 






HISTORY AND GEOGRAPHY 23 

For the same reason the malady is observed in 
wealthy districts such as Nemtzu and Becan. The 
chemist Lendway who analysed the corn submitted 
by Antoniu as the cause of the malady, found it 
tainted with Penicillium maidis and not with 
Sporisorium. 

Antoniu has made very interesting experimental 
studies with spoiled corn. Chickens fed on it for 
some weeks lost their feathers and drooped; in this 
condition they laid light eggs, having misshapen, 
porous shells with irregular surfaces, and they 
refused to sit on their nests. Dogs fed for six months 
on spoiled corn lost their hair and showed ery- 
thema. 

While physician to a penitentiary, Antoniu found 
that the corn furnished for the soup of the inmates 
was spoiled. He selected from the prisoners four 
workmen and three robust young peasants, and had 
them fed all winter on nothing but corn gruel. In 
the spring he examined them carefully, and found 
that all of them had become pellagrous. The work- 
men, who were from the city, had been in the habit 
of eating meat and cheese besides the regulation 
dietary. Also a banker, who ate corn meal gruel 
every day as well as cheese, became a chronic pella- 
grin. When he changed his diet the malady dis- 
appeared. 

The experience at Corfu is classical. There Pre- 
tenderis Thypaldos studied the history of the 
appearance of pellagra and the manifestations of 
the disease in the homes of 50 pellagrins. All had 
eaten spoiled corn. Some other communities, not 



24 PELLAGRA 

far from the villages where they lived, were free 
from pellagra, because in the latter millet and barley 
were eaten. In a village of Albanians where wheat- 
bread and fish were commonly eaten he found two 
persons affected with pellagra. They belonged to 
the poorest class and corn was their chief article of 
diet. 

Thypaldos remarks that this injurious influence is 
not explained by chemical analysis, for though corn 
contains perhaps less nitrogenous substance than 
wheat, it always contains more proteid than rye, 
which does not cause pellagra. 

Corn has been used for a long time in Corfu, but 
pellagra did not make its appearance there till 
within the last twenty years. Corfu has never been 
able to raise enough corn for home consumption. 
Additional supplies were imported from Epirus and 
Albania, equally as good as the home raised cereal, 
because harvested in the dry months. The peasants 
eat the unripe grain and expose the rest to dry 
in the sun, afterwards storing it in casks and 
grinding it later. Preservation is favored by the 
climate. Some years previous to these observations, 
very heavy rains had spoiled the corn crop. Later, 
in consequence of the extension of vine growing, 
the corn crop steadily decreased and it became neces- 
sary to import the cereal from Greece, Macedonia 
and the countries of the Danube, in addition to the 
supply brought from Albania. Because of the long 
sea voyage it always arrived at its destination in 
very bad condition. One community which had no 
pellagrins so long as it raised its own corn, now, 




Plate I. South Carolina case. Symmetrical lesions of bands. Skin dry 
and exfoliating. Color dark. Courtesy of Dr. J. J. Watson. 



HISTORY AND GEOGRAPHY 25 

having for seven years used imported corn, has 
nine of them to every six hundred inhabitants. 

The ready decomposition of corn is explained by 
the great quantity of fat contained in its embryo, 
equalling 63 per cent, of its weight, or two-thirds 
more than the fat contained in rye. The embryo 
not having any perisperm is more exposed to the 
air. Thus corn, if damp, is more subject to mould 
than any other cereal. 

[The percentage of fat given above is too high. 
According to Hopkins, Smith and East ("The 
Chemical Composition of Different Parts of the 
Corn Kernel") : "In corn of low protein con- 
tent the embryos constituted 9.59 per cent, 
by weight of the entire kernel. The fat content of 
the embryos was 36.54 per cent., while that of the 
entire kernel was 4.20 per cent. In high protein 
corn the embryos constituted 11.93 per cent, of the 
whole kernel. Its fat content was 33.71 per cent., 
while the fat content of the entire kernels was 5.36 
per cent." Joseph Schindler gives the following 
figures which are supposed to be averages for corn 
in the Tyrol: "Fat content of the entire kernel 4.2 
per cent., fat content of the embryo 22.0 per cent."] 

In Servia, Bulgaria and Koumania the number of 
pellagrins, which was 7,000 in 1894-5, was in 1906, 
according to Triller, 30,000*. The same increase has 
been noted in Turkey in Europe, in Greece, in the 
Ionian Isles, in Asia Minor, in Tripoli, in Tunis 
and finally in Egypt, In Egypt, first reported in 
1893 by Sandwith, pellagra has been observed by 

•De la Pellagre, Th. de Paris, 1906. 



26 



PELLAGRA 



Warnock, and on his recent journey by A. Marie. 
"The pellagrous affection," says Warnock, "attrib- 
uted to the eating of spoiled corn is evidently 
spread over the greater part of Egypt. A portion 
only of the fellaheen become insane. The number 
of these pellagrous lunatics admitted to the asylum 
at Cairo can give only a feeble idea of the serious- 
ness of the scourge. Sooner or later the govern- 
ment will have to take measures to combat its devel- 
opment." Furthermore, Warnock has noted at the 
Cairo asylum the presence of cases of insanity 
produced by pellagra.* These statistics of the cases 
under observation at that asylum in recent years are 
taken from his annual reports : 



YEAR 


MEN 


WOMEN 


TOTAL 


1896 


9 


2 


11 


1897 


10 


13 


23 


1898 


10 


29 


39 


1899 


19 


14 


33 


1900 


8 


27 


35 


1901 


27 


10 


37 


1902 


23 


10 


33 


1903 


41 


11 


52 


1904 


38 


15 


53 


1905 


54 


11 


65 


1906 


46 


13 


59 


1907 


69 


20 


89 


1908 


71 


17 


88 


1909 


68 


33 


101 




493 


225 


718 



•The Journal of Mental Science, January, 1902. 



history and geography 27 

Deaths from Pellagra at the Cairo Asylum. 



YEAR 


MEN 


WOMEN 


TOT^ 


1901 


6 


4 


10 


1902 


6 


2 


8 


1903 


9 


1 


10 


1904 


3 


3 


6 


1905 


13 


4 


17 


1906 


9 


1 


10 


1907 


7 


2 


9 


1908 


6 


2 


8 


1909 


10 


5 


15 



69 24 93 

In Spain, according to Triller, despite prophy- 
laxis, pellagra today affects 20 per cent, of the 
inhabitants of certain provinces. Casal, who first, 
in 1735, described pellagra in the Asturias, speaks 
thus of that severely tried people : 

"Corn is the principal food of the laborer there; 
soups are made of it to which they usually add milk ; 
likewise they eat eggs, fish and cheese; very rarely 
they buy fresh meat and occasionally salt meat." 

Here, as elsewhere, they began by misconceiving 
the real origin of the affection. 

Roel tried to prove that pellagra came from 
leprosy. But he recognized that pellagrins lived on 
corn.* Furthermore, he estimates that corn was im- 
ported to the value of 13,000,000 francs (or about 
$2,600,000), and of this 5,000,000 francs ($1,000,000) 
worth was imported by sea, but corn imported by 

•Etiolofjia della pellagra; Oviedo, 1880. 



28 PELLAGRA 

coastwise vessels is always damaged either by salt 
water or by rain. 

In Mexico several authors, among them Iturbide, 
have described erythemas combined with nervous 
troubles and gastro-intestinal disorders analagous 
to pellagra. But these cases have been questioned* 
and appear to have been confused with other affec- 
tions from which true pellagra ought to be distin- 
guished, but with which it can, however, be asso- 
ciated, as has been observed. An example is syphilis, 
which, combined with pellagra, may have caused the 
diseases reported from Mexico by Contreras and del 
Pinto (E. Sandoval and G. Tellez). 

In Ireland also they eat a great deal of corn, but 
it is put up in granaries and preserved by the 
Devaux system. (See page 324.) 

In France pellagra belongs to history, being a 
memory only, or very nearly so, since it has not 
figured for a long time in asylum statistics. Form- 
erly, however, it was a different story. Savoy, after 
its annexation to France, kept up for a long time 
the dietetic habits of northern Italy ; but the use of 
corn meal has greatly declined in Savoy since 1860. 
In the poor districts of the Pyrenees and of the 
Garonne basin and in the Landes, where Spanish 
influence prevails, the use of a corn dietary per- 
sisted up to the middle of the nineteenth century. 
Nevertheless, it was a mixed dietary that was 
incriminated by the investigating commission and 
its secretary, Theophile Roussel, who noted that the 
epidemic exacerbations of pellagra coincide with 

•Vide Coindet, 1869. 



HISTORY AND GEOGRAPHY 29 

the seasonal periods when much corn is used, while 
both meat supplies (mutton, pork, fish) and vege- 
tables (millet, rye, cabbage, pumpkins) are scarce. 
Actually, the little corn now consumed in France is 
of a better quality and well prepared. Hence pella- 
gra has disappeared. [It is not to be forgotten, how- 
ever, as is pointed out elsewhere, that the disappear- 
ance of pellagra also coincided with a general 
amelioration in the lot of the peasantry.] 

Since the first communications of Jean Hameau 
to the Koyal Society of Medicine of Bordeaux in 
1829, up to 1880, observations, investigations, reports 
and publications of every kind have followed one 
another without interruption. Learned societies, 
medical journals, Italian and French, the oldest 
French review of psychiatry (Les Annales Medico- 
Psychologiques) , have been filled with interesting 
observations on this subject. But, as Regis remarks, 
silence quickly followed in France, and for the last 
twenty years only a few cases have been reported, 
even from the region of Bordeaux, where the 
pellagra of the Landes has justly stimulated inquir- 
ing minds for a half century. What has happened ? 
And how shall we explain this sudden change? Is 
it that pellagra has disappeared from the Landes, 
or have the people become accustomed to it and lost 
their interest in its ravages, after having once been 
so much concerned ? The response to this interesting 
question has been given by Regis himself* in no 
uncertain manner, and we are permitted to say after 

L'EncSphale No. 4, 25th Aug., 1907. 



■^« 



30 PELLAGRA 

his last researches that pellagra does not exist any 
longer in the French Landes. 

As far back as 1879 Desmaisons, in his report 
on pellagra in southwestern France, drew conclu- 
sions showing the decrease of this endemic disease; 
and since that time the opinion generally enter- 
tained, and expressed in works like those of Dupuy 
and of Chambrelant, has been that this decrease has 
become more and more pronounced. 

At the asylums at Pau (St. Luc) and at Audi, 
the researches of our colleagues have furnished con- 
firmative results. "During the period of thirty 
years," says Girma, "from 1875 to 1905 inclusive, 
we have admitted 26 pellagrins, of whom 13 were 
men and 13 women, and of these the last case dates 
back to 1895. These patients were all Landais, 
except 3, who were originally from Basses-Pyrenees, 
upon the confines, however, of the Landes. It is only 
among the poverty-stricken that pellagrous manifes- 
tations occur. The annual average of the admis- 
sions of Landais from 1876 to 1905 was 33. In a 
total of 811 admissions 23 pellagrins were found. 
The symptoms of these insane pellagrins were almost 
always those of melancholia. Sometimes a rather 
short phase of violent excitement, suggesting acute 
delirium, has been observed, but a stage of melan- 
cholia followed the agitation, terminating sometimes 
in death, sometimes in recovery." 

Dr. Chevalier-Lavaure no longer observes pellagra 
in the asylum at Auch; but further inquiry should 
be made to learn from the antecedents of these 
insane patients whether or not pellagra is heredi- 
tary. 



HISTORY AND GEOGRAPHY 31 

"Pellagra," adds Regis, "has almost totally dis- 
appeared from the Landes during the last fifteen 
years." We shall return to this disappearance of 
the pellagrous intoxication from France in order 
to explain the conditions of prophylaxis and of the 
extinction of pellagra elsewhere, for, unfortunately, 
it exists, and to a very serious extent, in numerous 
other countries at the present time. 

Confronted by these demonstrations and argu- 
ments as to the cause of pellagra, how can we 
account for the persistent negligence of govern- 
ments and of the public regarding its spread? 

It is because the public is hard to be convinced. 
The love of life appeals, then cupidity conquers the 
love of life. The renowned teachers in medical 
centers do not live in the country, and being city 
dwellers, they do not appreciate the real gravity of 
the situation. Moreover, the few good observers 
living in the country, are too systematically led 
astray by ignorant people. Pellagra is sometimes 
hereditary, and thus does not originate directly from 
damaged corn; sometimes it shows itself in persons 
affected with malaria, alcoholism, puerperal disease, 
or from the consequences of depressing affections, 
and then it is easy to invoke a determining cause 
other than corn, if the symptom-complex should be 
misinterpreted. 

In those regions where pellagra is just beginning 
to manifest itself, but has not yet involved a large 
part of the population, as for example, near Rome, 
or near Perugia, it is easier to discern the causes of 
it, than in places like Milan and Bergau, where the 



j 



32 PELLAGRA 

disease has persisted for a century, but is carefully- 
concealed by the persons who are either responsible 
for it, or connive at its development. As Jacini has 
said, cupidity and ignorance lead man to the worst 
actions; the least scrupulous can make excuses. 
Many even believe they do right in giving damaged 
corn to their workmen, because in this way they can 
feed their help at less expense. But if they knew 
that they were thus giving them not only an inferior 
food, but a veritable poison, they would doubtless 
abstain from doing so. Few persons are convinced 
that moulded corn is truly a poison ; or if they have 
heard that the fact has been demonstrated by experi- 
ment, they also know that several well-known 
authorities have combated this hypothesis, and have 
been able apparently to refute the maize theory. 

When Marzari (1810) incriminated corn as the 
only cause of pellagra, all his confreres attacked 
him; and the great Congress of Medical Societies 
of 1859 approved their attitude. The Royal Insti- 
tute of Sciences of Lombardy, in 1874, officially 
opposed Lombroso's teaching by declaring moulded 
corn to be harmless (Relat. Biffi). 

In many regions corn, originally from Mexico[?], 
a country with a dry climate, is harvested either 
prematurely or late. In such countries it is fre- 
quently gathered after the rains of autumn have 
inundated the fields and barns; or else, exposed to 
sea water and rain in coasting vessels, it is spoiled 
during transportation. In upper Italy the barns 
are often so poorly built that the rain penetrates 
and, consequently, moulds develop on the harvested 



HISTORY AND GEOGRAPHY 33 

grain; then with the heat of summer the corn, which 
is insufficiently aired, rapidly decomposes. Often 
also the miller passes steam over the meal in order 
to increase its weight, a process which renders it 
damp and again prepares the way for mould. 

Still more injurious is the custom of making with 
bad meal large round cakes of which the portion 
just within the crust is scarcely cooked while the 
interior remains sodden and rapidly decomposes. 
There are also the fraudulent processes practised by 
the bakers who, in the country, are often protected 
by the local officials. 

That there is a correlation between the increase 
in the number of pellagrins and great humidity 
has been proved for Venetia especially. Parallel 
statistics have been prepared showing the rainfall 
and epidemic manifestations of pellagra; and these 
are found to coincide from 1877 to 1888. Cloudy 
weather is also a factor of influence in upper Italy, 
especially in the provinces of Venetia and of Udine, 
in favoring the development of moulds. All facts 
conspire, therefore, to show that the provinces of 
Venetia, Udine and Treviso have a climate in which 
corn cannot reach maturity and, in consequence, 
easily becomes the medium for parasitic growths in 
which the flora of these provinces is particularly 
rich. 

Let us now see what are the principal objections 
to the hypothesis of spoiled corn as a cause of 
pellagra. They have been numerous, but can be 
reduced to these three : cupidity, ignorance and deep 
poverty. It cannot be disputed that pellagra is a 

3— p. 



34 PELLAGRA 

disease of helpless poverty, developing from objec- 
tionable food, from grain itself badly sown, badly 
harvested, badly preserved or badly transported and 
prepared. Abject poverty is indeed a cause of 
eating spoiled corn; and the objection that such 
poverty is a necessary preliminary does not hold 
good, though the geography of pauperism coincides 
in certain respects with the distribution of pellagra. 

When polenta [a mush or porridge made of corn 
meal and universally eaten by the peasantry of 
northern Italy] is fresh, says Miraglia, the family 
remains well; whereas, pellagra makes its appear- 
ance when a great potful of polenta, enough 
to last the family a week, is made at one time of 
soured meal. This is done in certain regions by the 
poor and ignorant. Corn is thus liable to become 
harmful after its preparation for use as food. In 
many districts around Parma the use of bean cakes 
saves the people from pellagra, which prevails so 
extensively in the neighboring territory of Reggio. 

At Chieri, in Piedmont, since the development of 
the weaving industry, the amelioration of living con- 
ditions has extended even to the country districts, so 
that the small farmer is living better; and if here- 
after he continues to feed the damaged corn to the 
hogs pellagra will diminish. In Calabria, Pasquali 
has, it is true, found moulded corn, but the farmers, 
being prosperous, do not eat it when spoiled. How- 
ever, a new source of pellagra has manifested itself 
in the district of Girifalco since the introduction of 
corn bread. At Cava Carbonara there are no pella- 
grins, while in the neighboring communes they are 




HISTORY AND GEOGRAPHY 35 

numerous, but from this territory there is a great 
emigration at one season, followed by a later return 
with savings, which permits the people to enjoy 
wheat bread and good corn bread. Near Pa via, two 
villages exposed to frequent inundations have the 
same climate and the same soil; the one, Santa 
Zenone, is in the hands of numerous small pro- 
prietors who rent to their farmers on favorable 
terms — there no pellagra is found. At Pieve, Porto- 
Morone, on the contrary, the land is in the hands of 
large proprietors; high rents force the peasants to 
eat corn and to deny themselves pork and beef ; and 
so the disease is prevalent. 

In the neighborhood of Eovigo the terms of land 
rental are favorable. The laborer there may secure 
a piece of land for his own use. There is found 
there, nevertheless, a certain quantity of spoiled 
corn, which, however, is not eaten by the peasant. 
The pay of the day laborer is significant from our 
point of view, as we shall presently see. In the 
vicinity of Brescia are two villages, very near 
together, Rovato and Cuzzago. The one has a very 
fertile soil and the other very poor; in the former 
the system called schiavatico exists, which pays 
ludicrously small wages per day; in the latter, the 
proprietors, in order to rent their holdings at all, let 
the small farmers have a third of the annual yield, 
and this is why they are enabled also to raise barley, 
rye, etc. So the peasant then is in a situation which 
permits him to live better. It is in this way that 
the poor return of the soil preserves him from the 
malady of his corn- fed neighbor. At Gardone pel- 



6K) PELLAGRA 

lagra prevails proportionately with the control of 
land by large owners; a small crop of corn is dried 
easily; a large one, with difficulty, and it therefore 
spoils more easily. This is the reason the large 
landed estates, controlled by wealthy landowners, 
are here the cause of the propagation of the disease. 

The quarantines (forty-day crop) is the product of 
the last harvest of corn made in autumn, which the 
Italian proprietor leaves to his farmers, or to his 
day-laborers. This corn is hung on the outside of 
the huts and rarely dries as it should; in damp 
years it decomposes quickly. 

Imported corn, damaged by salt water, costs five 
francs* a bushel (boisseau), while good corn costs 
nine. In the villages often inundated by the Po, 
dampness is almost constant, so that after harvest 
the corn is always spoiled ; frequently, also, the har- 
vesting is done before complete maturity. Corn is, 
therefore, never eaten in that region except in bad 
condition. 

As it is difficult to sell unsound cereals, they are 
consumed where grown, and the preference is, of 
course, to assign them to the peasantry. 

When the division of the crop is made between 
the proprietors and the small farmers, the latter are 
compelled to accept a certain quantity of bad corn, 
and they are not in a position to decline a variety of 
food which neither they themselves nor the farm 
managers regard as poisonous. 

*The author throughout seems to use franc and lira inter- 
changeably ; and since, for all practical purposes, the value of each 
is about the same, twenty cents, we have also used them inter- 
changeably. The same may be said of centime and centesimo, each 
being worth about one-fifth of a cent. 






HISTORY AND GEOGRAPHY 37 

The Piedmont Commission on Pellagra has very 
properly cited Biella as a place free from pellagra 
in spite of a large consumption of corn. In this 
industrial town of upper Italy the workman is so 
well paid that he refuses to eat polenta, or bread 
made of damaged corn. The economic improvement 
at Biella has, therefore, caused pellagra to decrease, 
but this has been done by removing the necessity of 
eating spoiled corn. 

Near Innsbruck the corn is dried on the interior 
of houses upon a kind of screen which extends from 
the roof to the ground. The corn being dried by 
this method, the people know nothing of pellagra. 
But still this is possible only for the small land- 
owners. 

Around Pavia pellagra is little known, because 
ovens are in use for drying the corn ; rice, too, is cul- 
tivated there, and they make bread of it. Although 
this has not so good a taste, it has also not the dis- 
advantages of corn bread. 

In the territory of Brianza pellagra is endemic 
because, though the soil is dry, the grain is stored 
in silo-like pits made of beaten earth. 

In certain communities the heredity of pellagra is 
a cause of degeneracy still more destructive than 
the eating of damaged corn. So it is at Colla, near 
Reggio, at Inverno, near Pavia, at Dolce and at 
Rivoli, near Verona, at Sermide, near Mantua, 
where almost all the families are affected by hered- 
itary pellagra, and one can no longer say that the 
malady is due to the direct influence of corn. This 
situation, which has often been concealed for shame, 



38 PELLAGRA 

has complicated the researches in regard to the 
etiology of the disease, for men were seen to become 
pellagrous who no longer ate corn, and who often 
were rich, but suffered from the consequences of an 
hereditary vulnerability. 

Together with the abject poverty, the ignorance, 
vanity and credulity of the poor consumers must 
be reckoned the dishonesty of the farmer-merchants. 
One can find spoiled corn in all the granaries and in 
all the great grain markets, as also in the com- 
munal warehouses, but one does not find it unless 
he is warned, so to speak, to conceal all appearance 
of distrust. If the farmer suspects that an inquirer 
comes officially or officiously, he will sell to the mer- 
chants in order to hide the basis for making a report 
to the sanitary police. Many a time at the beginning 
of his investigations one of us had reason for report- 
ing this fact: 

"Having heard that a great quantity of Roumanian corn 
had arrived at Ancona, I asked for two sacks of it. The 
dealers replied in fear that the corn had to be inspected 
by the sanitary police; that they would not sell just two 
sacks, that it was necessary to call for fifty at least. It 
is for this reason that at Sissa the official Commission on 
Pellagra arrived at the conclusion that there did not exist 
any connection between the malady and the consumption of 
corn, for the countrymen of Sissa were accustomed to eating 
only corn of the best quality. When I went there I found 
in common use a meal of Roumanian corn which was com- 
pletely spoiled and was sold at a low price. I had the 
Parma Board of Health informed of it, and when these 
gentlemen did not wish to believe me, I conducted them to 
two of the largest corn merchants, who offered us some 
hundreds of sacks of it because we had assumed the role 
of merchants." 






HISTORY AND GEOGRAPHY 39 

When one appears as a representative of Boards 
of Health there is naturally never any spoiled corn 
for sale. Besides not infrequently corn offered for 
sale is made to appear of good quality because the 
merchants, and even the peasants, have learned the 
trick of manipulating it with plaster in such a way 
that its defective grayish spots are concealed. Often, 
also, the bad corn is at the bottom of the sack or 
mixed with the good. When fraudulent manipu- 
lation is not done with the unground cereal it is 
done with the meal by the millers. The buyer does 
not then observe anything unnatural, and conse- 
quently cannot trace the cause of his illness. 

How can any one be astonished that the peasant 
does not discern the cause of pellagra, when one 
knows that the peasant himself misconceives more 
or less conscientiously and conceals from the phy- 
sician the causes of other maladies, such as syphilis,, 
scrofula, etc.? His errors were, otherwise, those of 
the metaphysicians, of which they are the remote 
popular survival. It is thus that today the people 
believe in the herpetic, scorbutic and solar etiologies 
as held by the physicians of old. In the neighbor- 
hood of Verona the peasants claim that pellagra 
comes from the rays of the sun, which burn the skin ; 
at Parma they attribute it to the damp air; at 
Vicenza to eczema. 

Vanity also plays its part. Near Vicenza, for 
example, the physician, for his own sake, needs to 
take care not to say to a peasant that he has pellagra. 
"The patient has the salt rheum," or "an accidental 
eruption" — but never "pellagra." In this region the 



4:0 PELLAGRA 

term is synonymous with insanity, and for this rea- 
son no one will admit having it even in a mild form. 

The poor peasant, full of vanity, as all mortals, 
wishes to pretend that he eats wholesome food, at 
least wholesome corn, which is his staff of life, and 
he denies that he eats it spoiled, because he feels 
ashamed of his poverty, or, indeed, because he feels 
responsible himself for the bad preparation of his 
food. On the market and in the granaries of Villa- 
f ranca there is no lack of cheap corn, which has been 
gathered prematurely. An explanation is that the 
laborers stole it from the landowners by sackfuls 
from the field and sold it, or, it may be, concealed it 
for their own use. It is such corn, dried too late, 
that easily moulds. 

But often the peasant does not realize that this 
change has taken place, for his attention has not 
been called to it. The diverse symptoms of the 
beginning of the chronic disease confuse him. Some 
are even so ignorant that they add spoiled corn to 
their meal, because of its piquant and aromatic 
taste. Certain persons contend that spoiled corn 
facilitates their digestion. For instance, Costallat, 
in the Landes, has seen bread seasoned by spurred 
rye because of its peculiar flavor. 

Sometimes a district, in spite of the exclusive use 
of corn, remains free from pellagra. This is 
because there are local reasons which prevent its 
development. Jacini observes, for example, that 
pellagra appeared late in the mountains of Lom- 
bardy, because the difficulties of transportation kept 
up higher prices there; an expensive article of mer- 










I 




r 



Plate II. Illinois ease. Pellagrous "glove." Courtesy of Dr. G. A. 

Zeller. 



. 



HISTORY AND GEOGRAPHY 41 

chandise can not be sold if of bad quality. Up to 
his time they did not import corn from the ports 
of the Black Sea. Later, because cheap, this corn 
gained entrance, but was not used in the mountains 
at first except as food for hogs. 

We always discover in the final analysis the 
reciprocal relation which exists between poverty and 
the causes which are recognized as essential for the 
toxic alterations of corn, namely : the extension of its 
planting, defective transportation over the sea and 
the humidity of mountain climates. 

[In this connection it may be pertinent to refer 
briefly to a universal inquiry now being made in 
the United States as to whether the more or less 
recent appearance of pellagra here can in any possi- 
ble way be explained by changes which have taken 
place, in recent years, in methods applied to corn 
culture, etc. 

McCampbell* has suggested that in the Southern 
States when harvesting corn the old and better 
practice of "topping" has been largely replaced by 
that of "cutting and shocking," and that this latter 
method may produce better conditions for spoiling 
of the grain. 

Alsberg, of the Department of Agriculture at 
Washington,* disclaiming any intention of express- 
ing an opinion on etiology, has recently discussed at 
some length this entire question. 

With regard to the Southern States he shows 
that a great deal of corn is consumed there; that 

•Confer, on Pellagra, Columbia, S. C, 1908. 
*X. Y. Med. Journal, xc, 2, 50. 



42 PELLAGRA 

an insufficient supply is grown for local consump- 
tion and a great deal is in consequence imported 
from the corn belt. So far as Southern agricultural 
methods are concerned, the varieties of corn planted 
have been much changed; and the adoption of the 
principle of "rotation of crops" has caused a ten- 
dency to discontinue the old practice of "topping" 
and to resort to that of "cutting and shocking," 
which often results in harvesting the grain pre- 
maturely, and probably places it under very much 
more favorable conditions for spoiling. He also 
points out the difference in the process of milling 
between the Southern States and other sections. 
In the latter the germ, which is the part of the 
grain most easily spoiled, is almost entirely sepa- 
rated and is discarded, while in the former it is 
ground in with the meal. 

With regard to methods in the corn belt, he states 
that the varieties of corn planted in the last decades 
have changed greatly, with a constant tendency 
towards increasing the oil content of the grain. 
Most of the oil is in the embryo and this part of 
the grain is most subject to change (moulding). 
Hence grain with a large embryo not only spoils 
more readily, but if spoiled, its toxic content would, 
of course, be greater. In speaking of climatic condi- 
tions, he says that of late years there have been in 
the corn belt a series of cold, wet falls which have 
probably done a great deal to prevent proper ripen- 
ing of the corn. He also points out the dangerous 
extension northward of corn culture to climates not 
suited to its proper growth, and questions whether, 






HISTORY AND GEOGRAPHY 43 

with existing varieties, the northern limit of safe 
corn culture has not already been exceeded. The 
storing of the crop, too, has not always been properly 
looked after, and economic conditions have fre- 
quently begotten a temptation to harvest the grain 
prematurely. With regard to transportation, he 
comments on the folly, when shipping to warm 
climates, of using closed cars without ventilation, 
thus producing ideal conditions for over-heating and 
fermentation. 

Finally, Alsberg thinks that probably the most 
potent factor in the spoiling of corn is the water that 
is usually present, and suggests as a remedy a system 
of federal grain standardization.] 



J 



CHAPTER II 

General Statistics. 

Strambio in 1784 calculated that nearly one- 
twentieth of the population was pellagrous. In dis- 
tricts worst affected by the malady there was esti- 
mated to be one pellagrin in every five or six indi- 
viduals. By 1819 the proportion was increasing 
daily.* 

Visiting the hospital for the insane in Milan, 
Holland (1817) , among five hundred lunatics of both 
sexes confined in this establishment, found more 
than two-thirds of them to be due to pellagra. At 
Udine in 1883 there was an enormous recrudescence 
of pellagra, and the investigator Zinio, who traveled 
personally from place to place, reported that during 
the inundation of 1882 the inhabitants of the country 
districts found themselves face to face with the 
necessity of eating spoiled corn. At Sissa, the official 
Investigating Commission reporting on the question 
of the increase of pellagra stated that the inhabit- 
ants fed exclusively on meliga — a mixture of guar- 
antino and damaged corn meal imported from 
America. 

Inundations favor also the contemporaneous 
recrudescence of the swamp fevers, which coincide 
sometimes with pellagra, the development of which 
they favor by diminishing the power of resistance 
in malarial subjects. According to the prefectorial 
report of Sondrio it appears that in 120,000 inhab- 

*Dictionnaire des Sciences MSdicales, 1819, pp. 85 and 89. 






GENERAL STATISTICS 45 

itants there were 71 pellagrous, scattered among 
nine villages where malaria was endemic. The same 
observations were made in the plains of Bergamo 
and at Valcamonica, near Brescia. 

In Umbria, Adriani found the largest number of 
pellagrins in the neighborhood of Perugia — 278 — 
while at Foligno there were only two, at Orvielo 
nine, at Spoleto four, at Terni four and at Rieti 
none. The cause of this predominance of pellagrins 
around Perugia is the constant deforestation of the 
region which augments humidity and thus facilitates 
the decomposition of the corn. 

Lack of cleanliness in their dwellings is not a 
cause of the development of pellagra, since cases are 
numerous among peasants who keep their houses 
very neat. Likewise, the deprivation of wine is not 
to be reckoned as a causative factor, for in the years 
when wine is abundant and very cheap pellagra 
increases. Neither does abject poverty seem to enter 
as a direct factor in the increase of pellagra when 
it does not lead its unfortunate victims to the use of 
corn of dubious quality. In the neighborhood of 
Perugia the soil is extremely fertile; it is, further- 
more, cultivated generally by half-renters and on 
good terms. Some of them, nevertheless, have pel- 
lagra. They are not poor, but they are avaricious. 

There is a relation between bad harvests and the 
increase of pellagra; nevertheless, one cannot deny 
that abject poverty also favors indirectly the increase 
of the malady. The fact is that pellagra does not 
affect the poor alone, but also people in easy circum- 
stances, though it extends much more rapidly among 
the poverty stricken classes. 



46 PELLAGRA 

Adriani asks why pellagra appears always in the 
country districts and never among the poor inhab- 
itants of the cities. This is because the peasant alone 
consumes the spoiled corn. Many give damaged 
corn to their laborers because when it has a bad odor 
they eat less of it ; or, indeed, if they refuse it, they 
are deceived by an admixture of the good. The 
millers also, as we have seen, resort to the tricks of 
the trade. 

The poorest part of the population, deprived of 
cooking utensils, stoves, etc., and not knowing other 
modes of preparation, make for themselves with 
meal half-cooked corn cakes; even when made with 
meal of good quality these cakes rapidly undergo 
deleterious change. Their dietary includes also 
beans, different kinds of vegetables and sometimes 
acorns. In summer it is the custom to soak in soup 
the bread made from spoiled corn meal, as Adriani 
has shown in his investigations. 

That there is a relation between the importation 
of foreign Indian corn and a recrudescence of the 
disease should not be doubted for a moment. In 
the region of Perugia a harvest having been very 
bad, the land owners and the managers of the great 
estates supplied their renters and laborers with 
imported corn. The number of pellagrins increased 
in an alarming manner, and chiefly where foreign 
corn had been most used. That year, of 125 admis- 
sions to the insane asylum of Perugia, 49 were cases 
of pellagrous insanity. 

The influence of an Indian corn dietary is mani- 
fest also in the regions of Udine, Palma and 



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GENERAL STATISTICS 47 

Frindi. There a single village, Marano, is entirely 
free from pellagra. It is inhabited by 210 families, 
who. with the exception of 26 employees and fam- 
ilies of traders, live largely on fish (using each year 
2,600 quintals* of fish and eating no corn) . Opposite, 
at Sesto, which has 3,700 inhabitants, 700 being pel- 
lagrous, they use 1,500 quintals of Indian corn 
imported from foreign countries, while at Cassarsa 
the same number of inhabitants consume only 800 
quintals of corn, and there are there only 90 cases 
of pellagra. 

The relation between pellagra and nutrition by 
damaged corn meal is very apparent according to 
comparative statistics tabulated for 94 communes 
inspected. In 42 polenta made with spoiled corn 
meal was largely consumed. It was also in evidence 
several times that the polenta meal was badly ground 
and the broth not well cooked. Out of 3,964 pel- 
lagrins, 1,022 declared that they often ate spoiled 
polenta, 1,383 sometimes, and 1,385 never. (See 
table). Manzini, to whom we owe this information, 
also made investigations in other villages to learn 
why they used such food. In seven communes it 
was declared that the corn meal had fermented; in 
seventeen that poverty forced them to buy only 
damaged corn meal, because it was very much 
cheaper; in sixteen, because it was harvested before 
maturity and badly cooked; in thirteen, because the 
corn was sown on swampy ground, or harvested 
during a damp autumn when they were without the 
means for drying it. 

•A quintal is 100 pounds. 
4— P. 



48 PELLAGRA 

At the asylum which we visited the admissions of 
patients for pellagra for the years 1896 to 1906 was 
as follows : 

Year Men Women Totals 

1896 9 2 11 

1897 10 13 23 

1898.. 10 29 39 

1899 19 14 33 

1900 8 27 35 

1901 27 10 37 

1902 23 10 33 

1903 41 11 52 

1904 38 15 53 

1905 54 11 65 

1906 46 13 59 

Total 285 155 440 

Six large communes of Piedmont have officially 
declared that damaged corn meal is the cause of 
pellagra. In other communes it has been charged to 
the unhygienic condition of the dwellings, to nour- 
ishment on unripe corn, or, indeed, to its change in 
consequence of frequent storms. 

The Miraglia investigation revealed the fact that 
many communes had tried in vain to prevent the use 
of spoiled corn meal. At Ivree it was asked : "How 
can we prevent the people who have harvested 
nothing but Indian corn from eating it? Hunger 
is even more terrible than pellagra." At Polesella: 
"No measure of the sanitary police can prevent the 
poor people from eating the spoiled corn meal which 
is sold to them." 

At Rome it is well known that the inhabitants of 
the country eat every winter meal made from waste 



GENERAL STATISTICS 49 

corn. In the province of Ferrara the country people 
eat habitually spoiled meal; at Rovigo, as also in 
many Venetian villages, they eat damaged corn 
imported from foreign ports. 

At San-Apollinario (again according to the 
investigation of Miraglia) the laborers compel the 
proprietors to take good corn in exchange for that 
which is damaged; at Piacenza they complain of 
the bad quality of the Hungarian corn; likewise at 
Arezzo and at Siena. At Citta della Pieve, Lucca 
and Chioggia, the proprietors have the corn sorted 
and, instead of the good, give the waste to the 
laborers (Miraglia). At Costigliole, a village near 
Asti, in a region which is perhaps exempt from pel- 
lagra because it is rich in wine, Dr. Piccinini found 
a case of the disease in a peasant in good circum- 
stances who ate meat and in whose case, consequently, 
it could not be a question of insufficient nourishment ; 
but he also ate spoiled corn meal which he could not 
sell. 

Balestra relates in his work upon the Campagna 
Romana that pellagrins are found on certain farms 
where the people do not eat the corn grown upon the 
dry soil of the Campagna, but spoiled imported corn. 
In the district of Mantua thirty-three persons 
declared that corn spoiled because they harvested it 
in autumn and because it was shocked on the damp 
ground ; it then dries a very little, or even not at all, 
and in this condition it is threshed on the bare 
ground. At Sermide pellagra has increased because 
they are not only absolutely without ovens for drying 
the corn, but also without any sort of arrangement 



50 PELT, AGRA 

for aeration. The corn is brought up to the unpaved 
areas for drying; these areas are never repaired; 
the peasants do not give proper attention to the 
drying process, while the majority of laborers are 
compelled by necessity to have the meal ground as 
quickly as possible. The commission made special 
inquiry whether the corn consumed by the peasants 
and principally by the day laborers was always 
thoroughly ripe and sound. Thirty-nine communes 
responded affirmatively; 14 communes replied that 
the corn was not always mature; in bad years they 
used imported corn of inferior quality, or perhaps 
the day laborers bought it of the millers who habitu- 
ally sell the cereal damaged. It happens sometimes 
that persons having received good corn in payment, 
re-sell it in order to buy cheaper. Twelve communes 
declared that corn was often defective because it was 
harvested before maturity, or poorly dried, or pre- 
served in damp warehouses. 

It is noteworthy that where pellagra prevails it 
diminishes rapidly as soon as vigorous remedies are 
employed, or the commune establishes suitable dry- 
ing machines. 

For the last few years, in the province of Ber- 
gamo, there has been one pellagrin to every 107 
inhabitants; in the province of Milan one to every 
154 ; at Brescia one to every 41 ; at Cremona one to 
every 24. Since then the disease has spread consid- 
erably — in Valtellina, in Umbria, in Abruzzi, and 
even up to the neighborhood of Rome. In Lombardy 
the number of pellagrins rose in 1839 to 20,282; in 
1856 it reached 38,777, and went to 40,838 in 1869. 




GENERAL STATISTICS 51 

In Yenetia there were 20,000 pellagrins in 1853 and 
1856, and 29,830 in 1879. The sanitary investigation 
by the government in 1886 and the preceding one of 
Miraglia* showed that the number of pellagrins in 
Italy increased from 97,855 in 1879 to 104,067 in 
1881. During these two years the disease was more 
prevalent in Lombardy and in Venetia, and much 
less in Piedmont, in Emilia, in Marches and in 
Umbria. Some sporadic cases appeared in Liguria 
and Latium. 

It was in 1881 that the first four indubitable cases 
of pellagra were recognized in southern Italy — in 
the provinces of Teramo, Aquila, Chieti and Avel- 
lino, as also several doubtful cases in the provinces 
of Caserta, Benevento and Catanzaro. 

In 1883, 6,025 pellagrins were treated in 866 civil 
hospitals, of which number 923 died; in 1884, 6,944 
were treated in 993 civil hospitals, with 780 deaths ; 
in 1885, 6,982 pellagrins were under treatment. 

•Relazione sulla pellagra in Italia. 1884. 



52 



PELLAGRA 



The table below* shows the proportional mortality 
rate from pellagra in every 10,000 deaths, from 1881 
to 1887: 



Districts. 


1881. 


1882. 


1883. 


1884. 


1885. 


1886. 


1887. 


Piedmont 


77.1 

4.1 

387.8 

633.4 

290.6 

71.9 

50.3 

68.4 

2,1 


70.9 

1.4 

319.4 

500.2 

214.7 

63.6 

48.0 

62.2 


58.0 

4.1 

251.3 

397.4 

143.0 

34.3 

55.1 

38.8 


39.1 

12.0 

208.7 

323.4 

108.4 

29.1 

48.8 

37.9 


46.4 

5.3 

195.2 

313.5 

121.6 

24.8 

81.0 

49.4 

2.0 

2.3 


36.9 

2.3 

157.4 

374.8 

116.6 

53.8 

73.0 

37.0 

2.9 


24.3 






Lombardy 

Venetia 


92.6 
251.7 


Emilia 


79.5 




52.5 




60.9 




29.9 
















Campania 

Puglia 


0.8 
























Calabria 
















Sicily 


0.4 












0.4 

































*8tatistica Sanitaria, Ministero Intemo, N. 1890, Roma. 



GENERAL STATISTICS 53 

These statistics show the distribution of pellagra 
in Italy and also show the disease at its maximum 
in Venetia, Lombardy and Emilia; and at its min- 
imum in southern and insular Italy. For certain 
places there seems also an indication of an increase 
in numbers, with a diminution of intensity in the 
last four years of these statistics. 

These statistics are clearer for smaller territory. 
Thus, there were in the department of Udine in 
18T8 (with 181,386 inhabitants) 3,964 pellagrins, 
against 2,000 from 1858 to 1859. 

In the region around Lucca, Ceru found 896 
pellagrins in the period 1871 to 1875, and the num- 
ber was increasing every year. In the region around 
Mantua the disease is likewise on the increase, for 
against 1,228 cases in 1830 there were 2,195 cases 
in 1856, and in 1897 the number rose to 2,900. 

The figures become still more striking when we 
compare them with those of the pellagrous insane, 
where each case passes through a series of medical 
examinations before admission into an asylum. 

Pellagrous insane in Italian asylums: 

December 31, 1877 1,348 

" 1880 1,742 

" 1883 1,746 

" 1884 1,723 

" " 1885 1,741 

" " 1886 1,487 

" " 1887 1,342 

The statistics of Lolli and Lombroso on the admis- 
sions into the insane asylums of Pesaro and Imola, 



54 



PELLAGRA 



give for the period 1863 to 1872 the following 
figures: 





Forli and Imola 


Pesaro 


Ancona 


Bologna 


1863 


13 






64 


1864 


21 






15 


1865 


21 






27 


1866 


19 






44 


186T 


29 






44 


1868 


31 








1869 


48 


16 


8 




1870 


45 


6 


5 




1871 


33 


13 


6 




1872 


89 


15 


1 





In Emilia in the years of 1873 to 1877 the number 
of pellagrous insane showed the following changes : 

1873 1874 1875 1876 1877 

AtModena 38 48 16 17 31 

At Reggio 63 85 18 20 41 

One thousand two hundred and sixty-three pel- 
lagrous insane were received into the ayslum *of 
Mantua from 1869 to 1877 — consequently an average 
of 140 a year. During the first five years the aver- 
age was 124 ; in the last four years it rose to 161. 

Neusser reports 1,068 cases of pellagra in the 
Austrian Tyrol, in 1886, among 35,688 inhabitants, 
that is about 3 per cent, of the population. Of this 
number 96 pellagrins showed psychic disturbances, 
that is, 9 per cent. 

During their visit to the International Congress 
of Milan (June 7, 1906,) the authors of this work 
had the honor of being received at the asylum of 




a 

a 

<v % 

I 6 

5 P 



GENERAL STATISTICS 55 

Mombello, where they were able to examine a num- 
ber of pellagrous insane; they used the opportunity 
to compile complete statistics of these patients from 
1879 up to 1906. 

Pellagrous Insane Admitted from 1879 to 1906. 

Years Men Women Total 

1879 44 45 89 

63 72 135 

50 47 97 

69 53 122 

60 35 95 

41 53 94 

47 40 87 

56 60 116 

56 40 96 

59 63 122 

43 63 106 

52 47 99 

54 66 120 

72 67 139 

83 55 138 

49 51 100 

60 63 123 

73 50 123 

60 33 93 

75 61 136 

77 43 120 

65 38 103 

41 49 90 

47 24 71 

45 55 100 



56 



PELLAGRA 



1904 
1905 



37 
31 



1,509 



45 
31 



1,349 



82 
62 



2,858 



Deaths from Typhoid Pellagra in the Asylum. 

Years Men Women Total 

1901 2 1 3 

1902 3 1 4 

1903 1 3 4 

1904 1 .. 1 

1905 1 1 2 



8 



6 



14 



Districts of Origin of Pellagrous Insane in the 
Asylum. 

Abbiate- 



Years 


Milan Lodi Monza Gallarate 


grasso Total 


1901. . 


. 18 


8 


13 


13 


7 59 


1902. . 


. 17 


6 


12 


8 


4 47 


1903. . 


. 17 


13 


15 


14 


7 66 


1904. . 


. 14 


11 


15 


8 


11 59 


1905. . 


. 15 


5 


10 


4 


5 39 



81 43 



65 



47 



34 270 

Men 123 

Women 147 



270 



GENERAL STATISTICS 57 

Parallel with these yearly statistics of pellagrous 
insanity we have the report of the cases of ordinary 
pellagra noted in the province of Milan. According 
to this, out of 300 communes only 164 are still 
affected; these are precisely the ones which corre- 
spond to the five districts of the origin of the cases 
of pellagrous insanity, as shown in the table below. 

Districts Total Communes Pellagra Present 

Milan 78 37 

Lodi 68 29 

Monza 54 47 

Gallarate 58 29 

Abbiategrasso 42 22 



300 164 

[In a recent communication on pellagra to his 
department, Assistant Surgeon Wollenberg, U. S. 
Public Health and Marine-Hospital Service, reports 
from Naples, Italy, that : 

"Pellagra, despite the extensive interest which is 
being taken in its suppression, continues to spread 
in certain regions of Italy. A vigorous campaign 
has been waged against the disease for a number of 
years, laws concerning it have been enacted, improve- 
ments in grain culture have been encouraged, san- 
itation has widely improved; the number of pella- 
grins, however, is diminishing but slowly. The sum 
which is annually expended for salt, proper food, 
and hospital accommodations for the care and treat- 
ment of the poor affected with pellagra is enormous. 

"During the past twenty-five years the extent of 



58 PELLAGRA 

the disease has lessened considerably in the northern 
part of Italy — Piedmont, Lombardy, Venetia, and 
Emilia — while there has been a persistent spread in 
central Italy, very notably in Tuscany, Marches, 
and Umbria. The disease is now appearing in 
alarming proportions in Latium and in Abruzzo and 
Molise, compartments in which it was unknown 
some years ago. What is most striking is that the 
disease invaded southern Italy in 1908, cases having 
occurred in the vicinity of Naples and in Calabria. 
At present pellagra appears to be firmly established 
in the lower as well as in the upper portion of the 
Italian peninsula. The reason for this better show- 
ing in the north is not altogether plain, but is partly 
attributed to the economic, social, and sanitary 
improvements that have been effected there in recent 
years. 

"In the last triennium the disease was markedly 
reduced in the provinces of Arezzo, Bologna, 
Brescia, Florence, Forli, Macerata, Mantua, Modena, 
Padua, Pavia, Perugia, Pesaro, Eovigo, Treviso, and 
Venetia. An increase took place in Bergamo, Milan, 
and Novara. Statistics for central Italy show 
marked improvement in the province of Perugia. 
For the rest, the status remains nearly unchanged. 
In southern Italy there are new cases in the prov- 
inces of Avellino and Cosenza. In the same period 
the total number of new cases reported for the 
whole country has been gradually reduced as fol- 
lows: 



GENERAL STATISTICS 59 

New Cases 

1906 6,783 

1907 5,307 

1908 2,766 

"The total number of pellagrins in Italy at the 
present time may be estimated at less than 50,000. 
Considering that during the years 1906 and 1907 
pellagra was the cause of 1,873 deaths and 1,293 
cases of insanity, together with the long duration of 
the illness and its effect on the earning capacity of 
the afflicted individuals, the above figures are suffi- 
ciently startling. 

Total Number of Pellagrins by Census. 

Number 

1879 97,855 

1881 104,067 

1899 72,603 

1905 55,029 

******* 

"The mortality seems to be lessening. It changed 
very little after the law* of 1902 came into effect 
until the years 1906 and 1907, when there was a fall 
in the number of total deaths to less than one-fifth 
of those during the preceding years. 

Total Deaths from Pellagra in Italy. 

Number 

1898 3,987 

1899 3,836 



•See Appendix No. 1. 



60 



PELLAGRA 



1900 3,788 

1901 3,054 

1902 2,376 

1903 2,647 

1904 2,363 

1905 2,359 

1906 439 

1907 376 

"The hoped-for results and salutary intent of the 
law — to prevent the consumption of maize of poor 
quality — have hardly been realized. The law per- 
mits the milling of low-grade maize in case it is not 
to be used as aliment for man, but this provision is 
held to be difficult to enforce, proper sanitary super- 
vision of country districts being very difficult. 



Number of Pellagrins in Compartments by 

Census. 



Piedmont 

Liguria 

Lombardy 

Venetia 

Emilia 

Tuscany 

Marches 

Umbria 

Latium 

Abruzzo and Molise 



1881 



1,328 

56 

36,630 

55,881 

7,891 

924 

406 

872 

32 



1889 



1,223 

30 

19,557 

39,882 

4,617 

1,125 

920 

5,103 

146 



1905 



1,012 

56 

15,746 

27,781 

3,357 

1,137 

1,436 

4,250 

195 

59 






Public Health Reports, July 23, 1909.] 
[There are good reasons for believing that Italian 
statistics on pellagra leave much to be desired in 
point of accuracy.] 



GENERAL. STATISTICS 61 

[Pellagra in Austria-} A correspondent from 
Vienna under date of July 14, 1908, 2 says: In the 
eastern parts of the Empire a disease has been very 
prevalent among the poorer classes for some years 
past which has proved puzzling to the profession. 
The clinical symptoms somewhat resembled those of 
lepra, but differed in not having the anesthetic 
patches, with consequent dystrophic destructive pro- 
cesses. Profound cachexia with gastrointestinal 
disturbances are generally observed after the dis- 
ease has persisted for from 12 to 18 months. In 
many instances these were the only symptoms, while 
in other cases circulatory disturbances are a promi- 
nent feature. Similar cases were reported from 
neighboring districts of Russia and Roumania, and 
many scientists studied the disease. It was finally 
agreed by the majority of the investigators that the 
cause of the condition lay in the food. The peasants 
live largely on maize, making bread and other foods 
out of this material; a dish called "polenta," con- 
sisting of coarsely ground maize with lard, is par- 
taken of heartily daily. In certain wet years the 
corn was affected by a sporidium and became still 
more unwholesome because of the presence of certain 
toxic substances which are held responsible for the 
disease just described — pellagra. In the province 
mentioned, inhabited by 1,500,000 people, there are 
over 38,000 cases reported (3 per cent). 

In the same journal 3 the Vienna correspondent 
reverts to this subject under date of August 15, 1909 : 

^he remainder of this Chapter is by the Translators. 
Mour. Am. Med. Ass'n., Aug. 1, 1908. 
*Id. Sept. 4, 1909. 



62 PELLAGRA 

"Since 1905 the action of the government in sup- 
pressing pellagra has been going on and including 
all affected areas. Altogether a population of 
2,250,000 has been investigated with the result that 
about 78,163 persons (3 per cent.) were found to be 
suffering from one form or another of the disease. 
Certain districts were more affected than others, 
and, as a rule, the poorer classes succumbed more 
easily than those who could procure the food 
regarded as necessary. The measures of the govern- 
ment have been of a prophylactic nature." 

An account of pellagra in Transylvania is given 
in the Lancet, July 16, 1898, p. 164. Transylvania is 
in the Carpathian mountains, one side being inhab- 
ited by Hungarians; the other, by Roumanians — 
the descendants of Roman legionaries of the time 
of Trajan and his successors. 

When an endemic outbreak was reported from 
Transylvania a commission was appointed and con- 
firmed the diagnosis of pellagra. But fifteen years 
previously Dr. Takach reported suspicious cases of 
skin diseases which he named pellagra, but this diag- 
nosis was questioned by a dermatologist of Buda- 
pest. In 1897, however, special orders were issued 
to hospitals and asylums to be on the lookout for 
pellagra. Dr. Takach was the first to send in a 
patient suffering from pellagra. After that numer- 
ous cases were found. The disease was thought to 
be the result of insufficient nourishment, aggravated 
by bad hygienic conditions and by malaria. No cases 
could be detected where the people had good and 
sufficient food. The disease seemed to follow con- 



GENERAL STATISTICS 63 

tinuous rains, bad crops and murrain among the 
flocks. 

Pellagra in Roumania: As to the prevalence of 
pellagra in this country it is stated 1 that the staple 
food of the peasantry is maize, last year's harvest 
being 126,000,000 bushels. For some reason pellagra 
has increased. In 1901 there were 33,645 cases; in 
1905, 54,689 cases and in 1906 over 100,000 cases. 
Only three deaths from pellagra were reported in 
Bucharest, so that the disease is probably confined 
to the country districts, and may be one of the causes 
of the high mortality among infants. 

Pellagra in Great Britain: "Two cases of pella- 
gra have recently been recorded in patients who had 
never been out of the British Isles, but the published 
accounts do not tally with the disease as I know 
it, though the symptoms were somewhat similar to 
pellagra. One of the patients had never eaten maize 
but had devoured raw oatmeal and rice." — F. M. 
Sandwith, Conf. on Pellagra, 1909. 

Pellagra in Jamaica: Strachari's Disease. In 
1888 2 Dr. Henry Strachan, senior medical officer, 
reported 510 cases of "malarial multiple peripheral 
neuritis" observed in the Kingston, Jamaica, Pub- 
lic Hospital, full notes having been taken on 121 
of these cases. 

The patients complained of numbness and burn- 
ing heat in the palms and soles, often accompanied 
by cramps, worse at night and in wet weather. Im- 
paired vision and hearing were noted, and a feeling 

iBrit. Med. Jour., June 22, 1907, p. 1501. 
2 Sajous's Annual, Vol. 1. 

5— P. 



64 PET J, AGRA 

of constriction around the lower part of the chest. 
An eczematous condition appeared on the tops of the 
eyelids, the angles of the mouth, and the muco- 
cutaneous margins of the nostrils, the lips were 
unusually red and the palms hot to the touch and 
hyperemic. Later motor pains of upper and lower 
extremities appeared. Pain was constant, especially 
in the feet. Emaciation developed with the progress 
of the disease. Pigmentation of the palms, soles and 
lips appeared; respiration is impaired and death 
may ensue from paralysis of the respiratory 
muscles. Death is rare, recovery being the rule. 

The subjective symptoms are: (1) dimness of 
vision, (2) impaired hearing, (3) numbness and 
cramps of the extremities, (4) girdle pain, (5) joint 
pain, etc. 

The objective symptoms include: (1) trophic 
changes, (2) monoplegias, (3) altered gait, (4) knee 
jerk was absent in over one-half, exaggerated or sub- 
normal in 23 per cent., normal in rest, (5) cutaneous 
reflexes varied greatly, (6) sensations were blunted 
or impaired, (7) soreness of the muco- cutaneous 
lines of junction, (8) wasting of the muscles. 

Soreness of the muco- cutaneous borders, i. e. eye- 
lids, lips, urethra, anus or vulva, was almost the first 
symptom. Wasting and contraction of the muscles 
was very marked in extreme cases, the "claw" hand 
and foot being prominent features. The ophthal- 
moscope revealed some retinal hyperemia rarely 
amounting to optic neuritis, but pigmentation of the 
fundus was observed. Pigmentation of the brain 
and cord was the only feature observed post mortem. 
Strachan ascribed the condition to malaria. 



GENERAL STATISTICS 65 

Strachan reports further upon this condition. 1 He 
summarises the condition : (1) Widespread neuritis ; 
(2) Trophic changes in the skin, muco- cutaneous 
lines and occasionally the cornea; (3) Rare mono- 
plegias; (4) Disease is severe but may last months 
or years; (5) Recovery is the rule; a fatal termina- 
tion is rare. 

In the last stage when the patient is greatly 
wasted there may be delusions with feeble attempts 
at violence. In this condition they may be com- 
mitted to asylums. 

The eyelids are red and irritated. A slightly ecze- 
matous condition develops at the corners of the 
mouth and round the margin of the nostrils, with a 
fine, branny desquamation. A similar condition 
appears about the muco-cutaneous line of the pre- 
puce and more rarely about the vulva and anus. 
The lips and buccal cavity are hyperemic and there 
may be loss of surface epithelium on the tongue. 
Palms and soles are hyperemic due to dilated arte- 
rioles and later they are deeply pigmented, the color 
varying from brown to intense black. The gait is 
typically ataxic. The disease attacks both sexes, 
youths and adults." 

In discussing food poisons, Braddon 2 says: "An- 
other disease probably owning similar etiology is 
Strachan's Disease, occurring among the natives of 
the West Indies, which in some respects resembles 
pellagra. The West Indians live largely, too, on 



Practitioner (London) 1897, LIX, 477-84. 
*The Cause and Prevention of Beriberi, p. 47. 



66 PELLAGRA 

But, according to Dr. F. M. Sandwith, of London, 
in a private letter, it is impossible to tell what dis- 
ease Strachan is describing; certainly not pellagra 
or beriberi or malarial neuritis. Is it possible that 
his disease is post dysenteric neuritis, of which there 
is a good deal in the West Indies? The points 
against the diagnosis of pellagra are: multiple neu- 
ritis, numbness and cramps in hands and feet, dim- 
ness of sight, tightness around waist, burning in 
palms and soles, tenderness over ulnar nerve, patient 
kept awake at night rubbing feet and legs, atrophy 
of muscles producing claw hand, facial palsy, deaf- 
ness, scotoma, patients mostly get well, desquama- 
tion of palms and soles, skin eruption confined to 
muco-cutaneous orifices, palms and soles. Acrodynia 
might also be considered. 

In a recent report (Aug. 21, 1909,) to Surgeon- 
General Wyman, U. S. P. H. and M.-H. Service, 
F. van Dyne, American Consul to Jamaica, gives 
this additional history of this interesting condition : 

"In 1897 Dr. Strachan, the late senior medical 
officer of the Kingston General Hospital, described 
a form of multiple neuritis met with in Jamaica 
which he attributed to malarial intoxication, but Sir 
Patrick Manson, writing on 'beriberi' (Tropical 
Diseases) does not approve of this diagnosis of the 
causation of the disease and in a footnote writes as 
follows: 'Dr. Strachan has described a form of 
multiple peripheral neuritis which he calls malarial. 
The disease is endemic and very common in Jamaica. 
It differs from "beriberi" inasmuch as it is not 
attended with edema, is frequently attended with 
implication of the cranial nerves, and is rarely fatal. 



GENERAL STATISTICS 67 

We have no account of any similar disease of 
other tropical countries. Probably, therefore, Dr. 
Strachan's neuritis is not malarial, but depends on 
some other cause peculiar, so far as known, to 
Jamaica. The subject requires further study.' 

"Peripheral neuritis due, as it is maintained in 
Jamaica, to malarial intoxication, is fairly common. 
The wards of Kingston General Hospital are rarely 
free from these cases, but it is understood that not 
a single case of 'beriberi' has been met with in 
Jamaica. There are medical officers attached to the 
army here who are familiar with the disease, as it 
is seen and met with in the East Indies, and they 
have not found a single case in the Island. 

"Pellagra is often met with here, though rarely 
outside the walls of the asylum, and in last year's 
annual report the superintendent of the asylum here 
made the following reference to it : 

" 'Pellagra is fairly common in our wards. Steps 
are taken for the eradication of the disease by sub- 
stituting bread, sugar and fruit for the cornmeal 
rations. The result is waited for with interest and 
a definite pronouncement will be made in next year's 
report. Dr. G. L. Manning, the Medical Super- 
intendent of the Lunatic Asylum, Barbados, has 
reported similar cases there and he is of opinion the 
disease is communicable and recommends isolation 
of all patients.' 

"In this year's annual report the superintendent 
wrote as follows after twelve months' experience of 
a diet of cornmeal : 

" 'In continuation of my note in last year's report 



68 PELLAGRA 

on pellagra, a nervous disorder due, it is believed, to 
the consumption of damaged maize, the attempt 
made to eradicate the disease by the substitution 
of bread, sugar and fruit for cornmeal has proved 
but a partial success. There has been an undoubted 
diminution of the number of cases in our wards, 
but as several new cases occurred long after the 
withdrawal of the cornmeal, I am not satisfied that 
the condition is entirely due to the consumption of 
damaged maize, and purpose again restoring, though 
to a limited extent, cornmeal rations." 

Dr. D. J. Williams, Superintendent of the Asylum 
at Kingston, Jamaica, writes:* "The existence of 
pellagra was recognized in our wards about 12 years 
ago, but as then it was unknown in the West Indies, 
the correctness of the diagnosis was questioned and 
the erythematous condition of the exposed limbs 
attributed to 'sunburn.' 

"Four or five years ago the disease was very preva- 
lent in our wards; four per cent, of the inmates — ■ 
male and female in about equal numbers — were 
attacked in a population of 1,050. With generous 
diet, rest in bed and tonics, the majority improved 
temporarily; others made no improvement, but suf- 
fered from chronic diarrhea, progressive weakness 
and emaciation until death ended the scene." 

A corn free dietary, as noted above, was tried for 
twelve months, but the experiment did not satisfy 
Dr. Williams that maize is the only cause of this 
condition. In fact he records his opinion that 
Indian corn — damaged or otherwise — is not the sole 
cause of pellagra. 

♦Nat'l. Pellagra Conf. 1909, p. 230. 



GENERAL STATISTICS 69 

Pellagra in Barbados: Dr. C. G. Manning, med- 
ical superintendent of the asylum, Bridgetown, 
reports 1 that a disease has been prevalent there for 
about fifteen years which has been termed pellagra 
by some physicians, but he disagrees and considers 
the condition "Psilosis Pigmentosa." The chief 
characteristics are: The patient first declines food 
and soon refuses it. Examination shows the tongue 
stripped of epithelium along the tip and edges. The 
mucous membrane of the jaws and fauces is red and 
irritated. Soon intractable diarrhea sets in. Dark 
colored patches appear over the elbows, knees and 
knuckles. Later the uncovered parts of the feet and 
hands are affected. The patient rapidly loses flesh 
and becomes anemic. Mental symptoms appear and 
commitment to an asylum follows. Under regular 
diet and treatment improvement follows, but there 
is a tendency to recurrence. Some patients die of 
exhaustion. 

Pellagra in Yucatan, Mexico : Dr. G. F. Gaumer 7 
Izamal, writes: 2 "In 1882 in Yucatan locusts 
destroyed vegetation, especially Indian corn. Corn 
being the only cereal used in Yucatan for bread, 
famine seemed inevitable, until the merchants began 
to import it from New York. This importation con- 
tinued till 1891, when the country had recovered 
from the devastation of the locusts. The imported 
corn was brought in the holds of vessels as ballast. 
By reason of exposure to heat and humidity on the 
voyage, the corn underwent fermentation and 



iTrans. Nat'l. Pell. Conf. 1909, p. 232. 
•Id., p. 233. 



70 PELLAGKA 

became unfit for food. The constant eating of this 
spoiled corn led to the slow development of pellagra. 

"The disease was confined to the lower and middle 
classes, who were obliged to purchase the cheapest 
corn in the market. The wealthy class escaped, as 
they did not eat the imported corn. For the next 
ten years, 1891 to 1901, Yucatan produced enough 
corn for home consumption, and cases of pellagra 
no longer developed. The old cases ran their course 
fatally. From 1901 to 1907 the corn crops were 
almost total failures, and corn was again imported 
in larger amounts than ever before. Mobile and 
New Orleans were the chief sources of supply, but 
some came from Vera Cruz — all by water. Again 
pellagra became epidemic, but was not confined to 
the middle and lower classes as before. It had been 
found more profitable to raise hemp than corn, so 
all classes used the imported cereal. Consequently 
pellagra spread alike among the rich and poor. At 
the close of 1907, ten per cent, of the inhabitants 
were the victims of pellagra, and in August, 1909, 
not less than eight per cent, of the population had 
the disease." 

Pellagra in the United States:* A case of pella- 
gra was reported in 1864, by Dr. John P. Gray, of 
Utica, N.Y. In the discussion of this case a similar 
one was cited by Dr. Tyler of Somerville, Mass. 
Both of these cases were insane. In passing, mention 
should be made of an epidemic of a pellagra-like 
condition at the Halifax, Nova Scotia, asylum which 
was reported by Dr. J. DeWolff as occurring in 

•See Bibliography for references. 




Plate IV. Egyptian case. Same ease as Plate III. Pellagrous "mask. 



GENERAL STATISTICS 71 

1863. It is claimed by Dr. W. J. W. Kerr, of Cor- 
sicana, Texas, that pellagra was rife among the 
Union soldiers at the Anderson ville, Ga., prison at 
about the same time. Dr. H. N. Sloan asserts that 
pellagra was diagnosed in the South Carolina 
Asylum at Columbia, in the early 70s, but no 
written or printed record of it has been found. 
There seems to be no doubt that the disease existed 
among the insane patients in this institution in the 
early 80's, but was not properly diagnosed, being 
attributed to burns by the sun or fire. Dr. D. S. 
Pope, of Columbia, is now satisfied that at least two 
cases of pellagra occurred in the South Carolina 
penitentiary in the middle 80's. 

Dr. S. Sherwell, of Brooklyn, N. Y., reported a 
case of pellagra in an Italian sailor in 1883. In 
1889, Dr. Bemis, of New Orleans, left a written 
diagnosis of a case in a white woman at the Charity 
Hospital of that city. In the same year a case of 
the disease occurred in North Carolina, according to 
a recent report of E. J. Wood and R. H. Bellamy, of 
Wilmington. Towards the end of the last century, 
F. M. Sandwith, of London, having discovered pel- 
lagra in Egypt in 1893, and suspecting that it 
existed unrecognized in the Southern States, cor- 
responded with medical authorities and local physi- 
cians in this country, but failed to establish his 
theory. Later he found an unrecognized case in a 
recent Italian immigrant in a Boston hospital, where 
it was classified with cases of cerebro-spinal menin- 
gitis then epidemic. 



72 PELLAGRA 

In 1902, Dr. Sherwell reported another case and 
H. F. Harris, of Atlanta, recorded a case of anchy- 
lostomiasis presenting all the typical symptoms of 
pellagra. In the next few years the diagnosis of 
pellagra was made in South Carolina, North Caro- 
lina and Alabama by at least one general practi- 
tioner in each State, but they neglected to place 
their cases on record. Still, the evidence is con- 
clusive that cases of the disease were recognized. 
Different asylum physicians in the South Atlantic 
States now concur in the opinion that pellagra has 
existed there unrecognized from 10 to 25 or 30 
years. Asylum physicians in other States made the 
tentative diagnosis of pellagra but abandoned it 
because of the supposed rarity of the disease, or 
because all the cardinal symptoms were not present 
in their cases. 

An epidemic of pellagra occurred at the Mt. 
Vernon, Alabama, asylum for negroes in 1906. 
These cases were studied by Geo. H. Searcy and 
E. L. McCafferty of the hospital staff, with the 
assistance of E. D. Bondurant, of Montgomery, and 
Isadore Dyer, of New Orleans. The outbreak was 
reported by Geo. H. Searcy in 1907. About Decem- 
ber 1, 1907, the diagnosis of pellagra was inde- 
pendently made by the officers of the State Hospital 
for the Insane at Columbia, S. C, and a careful 
report rendered to the State Board of Health. This 
report was given wide circulation. 

At about the same time } E. J. Wood, of Wilming- 
ton, N. C, had studied a series of cases and reported 
them in a paper entitled : "A Mixed Infection with 



GENERAL STATISTICS 73 

Tertian and Quartan Malaria Occurring in a 
Patient with Symmetrical Gangrene." 

The American disease was identified with Italian 
pellagra in the summer of 1908, independently by 
J. J. Watson and J. W. Babcock, of Columbia, S. G, 
who went to Italy to study the disease. In the 
spring and summer of 1908 pellagra began to be 
recognized quite generally through the South. 

Following reports made by Passed Assistant Sur- 
geon C. H. Lavinder from Wilmington, N. C, in 
the fall of 1908, the importance of the disease was at 
once recognized by Surgeon General Walter 
Wyman, of the U. S. P. H. and M.-H. Service, who 
said, "These reports indicate that the disease is 
more prevalent than has been supposed and that it 
may in future assume importance from public health 
and economic standpoints and should receive most 
careful study." 

Special attention was given to pellagra in 1908 by 
medical organizations in North Carolina, South 
Carolina and Georgia, as well as other States. 

The South Carolina State Board of Health held a 
conference upon pellagra in October, 1908, and in 
November, 1909, a National conference on pellagra 
was held in Columbia under the auspices of the 
same board. Briefly these are some of the more 
important steps in the progress of the present 
interest in this subject in the United States. 

Statistics upon pellagra have been unsatisfactory. 
In June, 1909, a study of the subject claimed that 
the records showed at least 1,000 cases of pellagra 
scattered through sixteen States, and a conservative 



74 PELLAGRA 

estimate placed the number at 1,500 cases in the 
Southern States since 1906. A year later the con- 
clusion was reached that pellagra exists or is sus- 
pected in thirty-three States and that the number of 
cases approximates 3,000 and that a total of 5,000 
cases had occurred in the last five years. 

Besides at the Alabama and South Carolina Hos- 
pitals interesting foci of pellagra have been observed 
at the insane asylums of Georgia, North Carolina, 
Florida, Louisiana and Virginia. 

In the summer of 1909 the disease was recognized 
as existing at the Cook County (Dunning) and Bar- 
ton ville (Peoria) Hospitals in Illinois. In June, 
1910, Passed Assistant Surgeon J. D. Long, U. S. 
P. H. and M.-H. Service, verified the diagnosis in 
nine cases in the Philadelphia Hospital for the Insane 
(Blockley). 

Several cases have been recognized in the public 
institutions of California. 

Special commissions for the study of pellagra 
have been appointed by the U. S. P. H. and M.-H. 
Service and by the Governor of Illinois and the 
State Board of Health of North Carolina. 

Pellagra in Cuba, Porto Rico and Panama: Very 
rarely cases of pellagra have been imported into 
Cuba from the Asturias and occasionally a tentative 
diagnosis has been made in natives, or residents, 
usually alcoholists or sufferers with sprue. (Juan 
Guiteras.) 

B. K. Ashford has reported one case in Porto 
Rico and J. A. Hayne two cases from the Panama 
Canal zone. 



general, statistics 75 

Geographical Distribution of Pellagra. 
The geographical distribution of pellagra is prob- 
ably more extensive than is known. This list 
includes only those places from which the disease 
has been reported. 

Endemic and Cases Relatively Numerous. 

Northern and Central Italy. Piedmont, Lombardy, 
Liguria, Venetia, Emilia, Tuscany, Marches, 
Umbria, Latium, Abbruzzi and Molise. 

Roumania. Wallachia, Moldavia. 

Austria-Hungary. Tyrol. 

Northern Spain. Asturia, Lower Arragon, Bur- 
gos, Guadalajara. 

Greece. Island of Corfu. 

Lower Egypt and Red Sea Coast. 

Endemic and Cases Relatively Few. 
South Western France. Gironde, Landes, Haut-and 

Basses Pyrenees, Aude, Haut Garonne. 
North Portugal. 
Austria-Hungary. Croatia, Dalmatia, Bosnia, Buko- 

wina, Transylvania, Herzegovina, Galicia. 
Servia. 
Bulgaria. 
Turkey. 
Greece. 

Russia. Bessarabia, Kherson, Poland. 
Algeria. 
Tunis. 

Mexico. Yucatan, Campeche. 
South Africa. Kaffirs, Zulus, Robben Island. 
United States. 



76 PELLAGRA 

West Indies, Barbados, Jamaica. 
Southern and Insular Italy. 

Sporadic. 
Asia Minor. 
India. North Behar. 
South America. Brazil, Argentine. 
New Caledonia. 
West Indies, Cuba, Porto Eico. 

Doubtful. 
West Indies. Other Islands. 
Central America. 

Geographical Distribution or Pellagra in the 
United States. 

Endemic and Cases Kelatively Numerous. 
Virginia, North Carolina, South Carolina, Georgia, 
Florida, Alabama, Mississippi, Louisiana, 
Texas, Tennessee, Illinois. 

Endemic and Cases Relatively Few. 
Pennsylvania, Maryland, Kansas, Arkansas, Okla- 
homa, Kentucky, California. 

Sporadic or Doubtful. 
Massachusetts, Iowa, Ohio, New Mexico, Colo- 
rado ( ? ) , Missouri, Vermont, Ehode Island, 
West Virginia, District of Columbia, New 
York (imported cases), New Jersey (im- 
ported cases), Indiana, Wisconsin, Washing- 
ton, and Michigan. 



CHAPTER m 

Study of Spoiled Corn — Its Physical, Chemical, 
Microscopic and Bacteriologic Characteristics. 

One may judge how seriously the Italians them- 
selves regard the eating of spoiled corn by the names 
given in the different dialects to express its odor — 
scagn, padul, muffito, pati, sobbotti, verdet, butta, 
arbolli, s?naserido, romatico, moffiet, etc. 

Spoiled corn may be distinguished on gross exam- 
ination by its cracked or wrinkled hull, its color of 
tawny gold, without lustre and with embryo 
enlarged and blackish; furthermore, it almost 
always shows external spots, of a brownish color or 
a greenish color like verdigris, which are due to its 
diseased condition. If the grain is cut into two sym- 
metrical halves, there is noticed the brownish peri- 
sperm and the discolored embryo instead of the 
normal white appearance. The mass of the. peri- 
sperm which is around the embryo is often changed 
into a kind of detritus and in its place there is a 
cavity in which little coleoptera or mites often nest. 

The embryo is almost always atrophied, so that it 
does not fill out its normal place between the 
perisperm and the hull of the caryopsis. Often the 
grains have their ordinary appearance, but with 
eroded points scattered over the surface, and these 
favor the development of moulds. From this results 
the greenish blue dust which is found on many 
grains, a dust which does not remain on the surface 
but penetrates into the interior. In many grains the 



78 PELLAGRA 

appearance of the moulds and of the acarus farina 
coincide. The acarus, owing to its movements, can 
be readily discerned with the naked eye. 

The meal of spoiled corn is easy to detect by its 
tawny yellow color, sometimes grayish brown, its 
slight flavor of mould, its aromatic odor and bitter 
taste. The merchants make a ready test of spoiled 
corn meal by rubbing a little in the hand; if the 
meal is sound the odor of polenta is given off; if 
damaged, it smells mouldy. [These characteristics, 
admitting such ready differentiation between sound 
and spoiled grain belong only to grain decidedly 
spoiled.] 

Chemical Eesearches on Spoiled Corn. 

If as an experiment grains of spoiled corn, 
imported in coasting vessels, are digested in 90 per 
cent, alcohol, their grayish yellow color changes 
into an intense red; the alcohol itself becomes red, 
and this color deepens with time. But if grains of 
sound corn are treated in the same manner they do 
not change color, even if they remain in the liquid 
two months, while the alcohol becomes lemon yellow. 
[This red color was not obtained by Babes and Sion 
in Koumania, and we have also failed to observe it 
here except with artificially spoiled corn.] 

In a dilute solution of caustic potash the hull of 
the grain of spoiled corn becomes at first reddish 
brown; later all the solution becomes brown and 
gives off a penetrating odor of spoiled corn. The 
more the decomposition of the corn has advanced, 
the more quickly the color change takes place. If 



STUDY OF SPOILED CORN 79 

this alkaline fluid is neutralized by tartaric acid, 
flakes of a coffee color are precipitated which have 
the odor of spoiled corn; these flakes are insoluble 
in water and ether, but are soluble in alcohol. This 
same reaction can be obtained with both meal and 
bread made of spoiled corn. With meal and bread 
of sound corn the reaction shows a lemon yellow 
color. 

The tincture of spoiled corn yields three sub- 
stances. The first is, at ordinary temperature, a 
liquid of ruby red color, with a strong, bitter taste 
and a very pronounced odor of spoiled corn. It 
is soluble in alcohol and ether, but insoluble in 
water, in which it floats; it becomes resinous when 
exposed to the air, and does not yield a precipitate 
with the iodide of potassium nor with the chloride of 
platinum, nor with other metallic salts. With 
caustic potash and benzine it yields a bright yellow 
precipitate, and a drop of it on paper makes a greasy 
spot. This tincture, then, contains the oily sub- 
stance of corn; it is colored by a red substance 
which can be isolated from the ethereal solution by 
caustic potash. Briefly, we shall call this oil the red 
oil of spoiled corn. 

The second substance is reddish-brown; styptic 
and bitter, is soluble in ordinary alcohol, but in abso- 
lute alcohol it precipitates yellowish flakes, which 
dissolve quickly if a little distilled water is added. 
It is also insoluble in ether and yields, when treated 
with iodide of potassium, a flaky precipitate; with 
chloride of platinum it yields likewise a flaky pre- 
cipitate of yellowish color; with sulphate of copper 

6— p. 



80 PELLAGRA 

it becomes green; at the end of a certain time a 
reduction of protoxide takes place; it is soluble in 
acetic acid and a solution of caustic potash, from 
which it can be precipitated by means of sulphuric 
acid; treated with much water it separates into two 
parts, one of which, insoluble, is precipitated in 
the form of a brown amorphous powder; the other 
makes a bright yellow solution. This is pellagrosine 
or the toxic substance of spoiled corn; and, as we 
shall see, its toxicity is very marked. 

The third substance, when heated with ether, 
solidifies into a mass which becomes hard on 
exposure to the air. It is soluble in diluted alcohol 
and in a solution of caustic potash; in water, abso- 
lute alcohol and benzine it is insoluble. When 
heated it becomes semi-solid and can be drawn out 
in threads like sealing wax; it burns with a white 
flame giving off the odor of burnt polenta; this is 
the resinous substance of spoiled corn. 

The tincture of sound corn yields likewise three 
substances. The one is not red, but is of a beautiful 
yellow amber color, is soluble in ether and has not 
the strong odor of the red oil of spoiled corn; it is 
not, like the red, precipitated when treated with ben- 
zine, does not become resinous when exposed to the 
air ; in short, it has all the properties of normal com- 
mercial oil of corn. The second is, likewise, yellow, 
does not yield a flaky precipitate with iodide of 
potassium nor with absolute alcohol, but with 
caustic potash and sulphuric acid yields a precipitate 
soluble in ether. The third resembles the resinous 
substance of spoiled corn. 



STUDY OF SPOILED CORN 



81 



In passing, it is worth noting that the substances 
isolated from spoiled corn are chemically analogous 
to those isolated from spurred rye (ergot) ; and the 
toxic substances of spoiled corn, if given in small 
doses for a long time, will show physiologic and ther- 
apeutic activity similar to those of ergot adminis- 
tered in the same way. 

Differential Chemical Reactions of 



Spoiled Corn 

Is colored red in alcohol 
and caustic potash. 

Yields with alcohol a red 
tint. 

Yields an oil, bitter, ruby- 
red, which is dissolved in 
alcohol, gives a precipitate 
with benzine, becomes resin- 
ous when exposed to air, 
contains a pigment which 
can be isolated by caustic 
potash from an ethereal 
solution. 

Yields a red substance, 
slightly poisonous, which, 
when dissolved in caustic 
potash and sulphuric acid, 
produces red-brown flakes, 
insoluble in ether. Precipi- 
tates in iodide of potassium 
reddish flakes, in absolute 
alcohol flakes of a pale yel- 
low color. 

The name Toxic Sub- 
stance of Spoiled Corn 
(Pellagrosine) is given to 
this body. 



Sound Corn 

Does not change color in 
alcohol or in caustic pot- 
ash. 

Yields with alcohol a 
lemon-yellow tint. 

Yields an oil of yellow 
amber color, without odor, 
insoluble in alcohol; does 
not become resinous when 
exposed to the air ; does not 
yield a precipitate with 
benzine, but dissolves at 
once. 

Yields a yellow sub- 
stance, which does not pre- 
cipitate either with absolute 
alcohol or iodide of potas- 
sium ; this product becomes 
liquid in sulphuric acid and 
ether and is absolutely 
harmless. 



82 PELLAGRA 

The chemist Erba perfected the method of ex- 
tracting these substances. He placed large quan- 
tities of sound corn in casks, filled about one-third 
full of water. These were shaken daily so that all 
the grain came into contact with the water. Daily 
examinations were made. The grain passed slowly 
through acetic, alcoholic, lactic and putrid fermenta- 
tions. At this stage it was dried. The grain was 
then seen to preserve its usual form, but had assumed 
a dark, dirty, yellow color, while the embryos were 
of an intense yellow and richer than normal in oil. 
The starchy part of the grain appeared grayish 
white. The corn to the touch was less compact and 
was easily pulverized. The microscope revealed an 
abundant growth of several moulds, including prin- 
cipally aspergilli, eurotium herbariorum, and oidium 
lactis. 

The corn was next dried till it lost 24 per cent, of 
its weight, ground, and the meal treated with 40 per 
cent, alcohol to extract soluble substances. Distilling 
this tincture on a water bath, and treating the resi- 
due, there were obtained an oily substance desig- 
nated as the oleoresin of spoiled com analagous to 
the red oil mentioned above; a substance identical 
with the alcoholic extract or pellagrosine ; a resinoid 
substance designated as the glutinous substance of 
spoiled corn; and a substance designated as the 
aqueous extract of spoiled corn. 

The embryos of spoiled corn, treated in a similar 
manner, yielded only an oil, or rather fat, which 
remained solid even at 19° C. ; and the alcoholic 
extract in small quantity. 



STUDY OF SPOILED CORN 83 

Corn bread (pane giallo), moulded and spoiled 
up to the lactic fermentation stage and exposed to 
moist heat, under treatment, yielded a greater quan- 
tity of fat of a yellow color and aromatic odor, 
which remainded solid at 19° C. Large quantities of 
sound corn, submitted to the same methods, yielded 
a very small quantity of oil and almost none of the 
alcoholic extract. 

From artificially spoiled corn there was obtained, 
from 15 liters of tincture (prepared from 100 kilos 
of corn) 3 kilos of oleoresin and 800 grams of pella- 
grosine. 

Submitted to analysis by Brugnatelli the oil and 
the alcoholic extract from spoiled corn showed the 
presence of a bitter, nitrogenous body, which gave 
the reactions of an alkaloid resembling strychnine. 
This alkaloidal body was not found in the sound 
corn. 

Micro-organisms of Spoiled Corn. 

We shall omit the discussion of Sclerotium maidis, 
analagous to the fungus of mildew of rye and bar- 
ley, which is found only in Colombia, where it causes 
in animals falling of the hair, the teeth, the nails 
and paralysis of the lower extremities (Roulin), 
but not pellagra. Nor shall we speak of the smuts 
Ustilago maidis and Uredo carbo, because grain so 
affected is not used, and therefore cannot have any 
direct connection with pellagra. 

There remain to be considered : 

1. Sporisorium maidis. This is the best known 
parasite of spoiled corn. The study of pellagra in 



84 PELLAGRA 

Italy began a new era with its description; it is of 
a greenish color and is observed in the furrow of 
the embryo, and, as seen under the microscope, 
resembles little globules united by fine filaments, but 
separable by rubbing. 

Balardini, who, with Cesati, was the first to 
describe this hyphomycete, experimented with it on 
man, and produced gastritis and diarrhea; with 
chickens it caused loss of feathers, decided loss of 
weight and droopiness. 

With regard to the etiology of pellagra, however, 
this micro-organism has no importance, for Lom- 
broso found only three specimens of it in Lombardy 
during many years. 

Balardini has not been able to find it again, 
even during rainy seasons. If an organism is respon- 
sible for a disease so widely spread as pellagra, it 
would itself be more widely distributed instead of 
being a curiosity. 

2. Penicillium. In all the spoiled grains a quantity 
of Penicillium glaucum is found, which exhibits per- 
pendicular filaments, from which are developed in 
great number flaky, easily scattered conidia. They 
compose the greenish-blue dust which is found on 
most of the grains of spoiled corn. This does not 
remain on the surface, but penetrates into the inte- 
rior, principally in corn placed on the ground level 
in the winter, or during fermentation in damp gran- 
aries. 

3. Oidium lactis maidis is composed of simple, 
spore-bearing, straight and colorless filaments, and 
a terminal chain composed of short, cylindrical 



STUDY OF SPOILED CORN 85 

spores of 0.0077 up to 0.0108 mm. in size. It develops 
at 19 degrees C, and the corn develops first alcoholic 
and later butyric fermentations. 

4. Eurotium herbariorum is found in the damp 
corn imported by coasting vessels from the Danube. 

5. Aspergillus glaucus is found in the same con- 
ditions as Penicillium, but more rarely. 

6. Sporothrichum maidis was found in 1873 by 
Professor Garovaglio on corn which had been 
exposed to storms. It was a new hyphomycete of the 
genus Sporothrichum , and is very rare.* 

With ordinary meal of spoiled corn one may 
obtain by cultural methods these micro-organisms: 

1. A very small, cylindrical bacillus, very motile, 
which multiplies by fission, 1 to 3 micra in length, 
y 2 micron in width, which grows in chains of two or 
three elements ; stains readily with an alcoholic solu- 
tion of methyl violet and with the usual aniline dyes 
as well as with dilute hematoxylin ; it resists a tem- 
perature of 90 degrees and grows luxuriantly at 25> 
and 30 degrees C. This is the bacterium maidis or,, 
better, mesentericus vulgaris (potato bacillus). 

2. Frequently another very small, short bacillus 
sometimes growing in chains, which stains well with 
the aniline colors — a variety of bacterium thermo y 
sometimes found in organic matter undergoing 
putrefactive changes. 

3. In many specimens of spoiled meal, or in bread 
made from it, is also found the true bacterium 
thermo, 1.5 micron in length, 0.5 to 0.8 micron in 
width. 

*Rendiconti del R. Istituto Lombardo, 1873. 



86 PELLAGRA 

4. In other specimens there is found the bacillus 
tremulus 3 to 7 micra in length, 0.4 micron in width, 
but its presence is not characteristic. 

5. Diplococci are found in small numbers, and 
numerous colonies of small micrococci which are 
equally common in putrifying substances and in 
good corn bread. 

It is to be noted that in many specimens of meal 
only the bacterium maidis is found, while at other 
times this organism appears in cultures along with 
many other organisms. 

Breads made of thoroughly tested meal were 
examined microscopically soon after leaving the 
oven. The potato bacillus was found in great num- 
bers. This bread, after being broken open, was 
placed in a damp chamber; at the end of eight or 
ten days it showed numerous yellowish and bluish 
spots, which, according to the examination of Pro- 
fessors Mattirolo and Gibelli were composed of the 
following micro-organisms : 

1. Rhizopus nigricans (Ehrenberg). 

2. Mucor Stolonifer (De Barry). 

3. Eurotium aspergillus glaucus (De Barry). 

4. Aspergillus glaucus (Linck) with many 
mature conidia. 

5. Bacterium maidis. 

6. Conidia which came probably from Oospora 
verticilloides ( Saccardi ) . 

7. Abundant mycelia, coming probably from 
a Pyronomycete (an absolute certainty is impossible, 
because pure cultures were not made) ; very likely 
from Oospora verticilloides. 






. 



STUDY OF SPOILED CORN 87 

It is worthy of remark that the bacterium maidis 
was also found in sound meal and in the bread made 
from this meal. The bread after analysis was given 
to dogs, and the results will be found further on. 

Cuboni found in spoiled corn and meal saccha- 
romyces mycoderma, and once a profuse develop- 
ment of sarcina ventriculi; he found Oospora ver- 
ticilloides on corn which had remained on damp 
ground, but never on corn imported by coasting 
vessels. But he devoted most of his attention to the 
bacterium maidis. 

In 1881, Majocchi found a very motile bacterium 
in both sound and spoiled corn, but always in greater 
numbers on spoiled corn — this micro-organism he 
called bacterium maidis, and he thought he found it 
also in the blood of seven pellagrins in the first stage 
of the disease. Cuboni, working with this micro- 
organism, found it constantly and abundantly on 
spoiled corn. He also called it bacterium maidis 
and recognized its similarity to the bacterium 
thermo, though it resisted a higher temperature. 

With corn very much spoiled by sea-water, this 
bacterium can very easily be recovered from the 
interior of the grain. 

This bacterium is not injured by a warm solution 
of chloride of sodium, or of sulphate of calcium, but 
is killed by arsenite of sodium in the proportion of 
.03 gram to 250 grams of polenta and by 0.5 gram 
sulphate of quinine to 200 grams. 

According to Cuboni, the development of the bac- 
terium maidis occurs in damp corn, and more readily 
still in immature corn. Dryness arrests its develop- 



88 PELLAGRA 

ment absolutely, but without destroying it. This is 
why corn well dried can spoil if it again becomes 
damp. This bacterium resists a temperature of 98 
to 100 degrees C, so that, even during the cooking of 
polenta, some bacteria survive. Cultures on gelatine 
show white points on the surface which spread 
slowly and liquify the medium. In a tube the cul- 
tures assume the funnel shape. 

Comparing the feces of healthy individuals with 
those of pellagrins, Cuboni arrived at the conclusion 
that the latter harbor much greater numbers of this 
bacterium ; when introduced by spoiled polenta they 
multiply enormously and occasion a true intestinal 
mycosis. 

Paltauf and Heider have likewise studied the 
peculiarities of the bacterium maidis. They give its 
length as 2-3 micra, very rarely 4-5 micra; its 
smaller forms are rounded at the ends and are very 
motile; sometimes they form long chains. It is 
colored by the usual aniline dyes, but especially by 
methylene blue. It is an aerobe which grows well 
at ordinary temperatures. Spores are found in the 
middle or at one extremity and occasionaly free in 
old cultures. In from 24 to 36 hours, gelatine plate 
cultures show superficial, circular colonies with irreg- 
ular edges and there occurs a funnel-shaped liquif ac- 
tion of the medium. Cultures on potatoes show a 
granular and wrinkled membrane. On agar and 
also in blood serum a very fine membrane appears 
which covers the entire surface; on corn meal it 
forms a grayish-white membrane, which later 
becomes brown and slowly liquifies. 






STUDY OF SPOILED CORN 89 

From all these peculiarities, they conclude that it 
is the potato bacillus. Paltauf searched for it in the 
feces of pellagrins and found it in fifteen patients, 
but its presence in the intestines of the pellagrous 
does not seem pathogenic. 

Heider, working in the laboratory of Professor 
Ludwig, at Vienna, studied the biology of bacterium 
maidis and its chemical products. According to 
these studies the bacillus is a strict aerobe, 
grows well in alkaline media, but will sur- 
vive in neutral or even slightly acid media. Albu- 
menoid media are broken up by this organism with 
the production of ammoniacal substances, traces of 
sulphur and an amine, probably the trimethylamine ; 
indol, skatol and phenol are absent. Starchy sub- 
stances are converted into sugars, and from sac- 
charine solution is produced a volatile body allied 
to the aldehydes or ketones, also acetic, butyric and 
perhaps a small quantity of succinic acids are 
formed. Milk is acidified and coagulated. These 
observations indicate that at a high temperature and 
with a certain humidity this bacillus can promptly 
produce changes in corn. 

Bordoni-Uffreduzzi and Ottolenghi have found 
that in polenta this bacillus resists an energetic ster- 
ilization. It is only after repeated sterilizations, 
under high pressure, that it ceases to develop. 
Polenta sterilized, infected with the potato bacillus 
and placed in the thermostat, becomes covered with 
a very thin membrane, ashy gray in color and with 
light folds, which thickens and at the end of five 
days becomes spongy in character. Later liquified 



90 PELLAGRA 

spots make their appearance and spread slowly over 
the whole surface; at the end of 20 or 30 days the 
polenta becomes of a thick, soup-like consistency 
with a dark cafe-au-lait color. Kept for some 
months at the same temperature, no further changes 
occurred. On the third day the culture develops a 
strong mouse-like odor. 

We shall return to the experimental results of 
feeding dogs with corn infected by this bacillus. 

Monti and Tirelli made new and very accurate 
studies of spoiled corn in the laboratory of Golgi. 
From time to time they ground their corn afresh 
under antiseptic precautions and used the plate 
culture method of Koch and Esmarch. 

They found fourteen different micro-organisms. 
The most numerous were the Penicillium glaucum, 
Eurotium herbariorum, Mucor racemosus, Oospora 
verticilloides and Bacterium mesentericum vulgare 
(potato bacillus) and Rhizopus nigricans, — none is 
directly injurious to the human organism, but all 
are notoriously capable of decomposing the cereals 
upon which they vegetate. Monti says: "It is easy 
to understand that Mucor racemosus and Rhizopus 
nigricans are important in the fermentative pro- 
cesses of corn." 

The presence of the saccharomycetes is explained 
by the great percentage of starchy substances con- 
tained in corn, but the presence of the putrefactive 
bacteria, like the bacterium thermo, indicates that 
in spoiled corn, besides fermentative processes, putre- 
factive changes also play a part. 

From another point of view, the presence of micro- 




STUDY OF SPOILED CORN 91 

organisms which are also found in water, shows that 
the corn is damp from rains, dews or dirt, and this 
justifies the ancient custom requiring that corn be 
dried under cover. It is more than probable that in 
consequence of the drying, many of the organisms 
die, and even the most resistant no longer find a 
favorable medium for development. 

[The moulds found on spoiled corn are very 
numerous and a great deal of study has been given 
to their relative importance on spoiled corn. Tira- 
boschi, under Gosio's direction,* has devoted much 
time to this subject. From an examination of 432 
specimens of spoiled corn obtained from places 
where pellagra was endemic and serious, he reported, 
at the end of two years' labor, the following moulds, 
named in the order of their frequency : Penicillium 
glaucum (Link), Oospora verticilloides (Sacc.) 
(Tirab.), Aspergillus niger (v. Tiegh), Aspergillus 
flavus (Link), Aspergillus varians (Wehmer), As- 
pergillus fumigatus (Fres.), Aspergillus ochraceus 
(TTilh.), Aspergillus effusus (Tirab.), Aspergillus 
glaucus (Link). 

These studies, Gosio remarks, confirmed the great 
preponderance of Penicillium glaucum over other 
moulds, but the low temperature at which this mould 
will develop has naturally resulted in its greater 
prevalence, and has, therefore, possibly given it a 
position of false importance. 

These moulds, as Tiraboschi states, are limited to 
three genera: Penicillium, Aspergillus, Oospora, 



*B. Gosio. Sul problema etiologico della pellagra — Atti del Terzo 
Congresso Pellagrologlco Italiano. 1907. 



92 PELLAGRA 

In a more recent paper (1908) Tiraboschi has com- 
mented on the varied flora of spoiled corn, and 
pointed out the importance of the regions from 
which such corn may have originated. And he 
describes three new moulds found by him on im- 
ported, spoiled corn, which had never been reported 
as found on spoiled corn previously, namely, Oospora 
aegeritoides (Karst), Harmodendron cladosporiodes 
(Fres.) (Sacc.) and Diplodia maidis (Berk.) 
(Sacc.)] 



CHAPTER IV 

Experimental. Researches and Etiology. 

Although very probably the cause of pellagra is 
to be found in the chemical and molecular changes 
which take place in corn under the influence of 
numerous micro-organisms, practically innocuous in 
themselves, which vegetate on this grain, yet it is 
difficult to find the remote and indirect cause of the 
malady [that is, the particular parasite or parasites 
responsible for the production of the specific tox- 
ins] . It is useless to delay over the question of the 
harmlessness of the very frequent Penicillium. The 
administration to three persons of half a grain of 
spores of Penicillium glaucum from corn produced 
no other result than a metallic taste and burning in 
the pharynx. A subcutaneous injection of .02 gram 
gave only a local inflammatory reaction. Two rats 
fed for 20 days on this same mould, taken from corn 
bread, lost weight but presented no pellagrous symp- 
toms. Grohe showed that spores of Penicillium and 
Aspergilli injected intravenously in dogs gave no 
toxic symptoms. According to Carlo Ceni, the 
Penicillia, however, have a direct poisonous action. 
[Ceni's work will be discussed elsewhere.] But 
according to Monti, the Aspergilli in symbiosis with 
other micro-organisms must be charged with set- 
ting toxalbumins free. 

Tizzoni, on the other hand, considers only the 
microbic action and undertakes the task of demon- 
strating that in the grave and rapidly fatal forms of 
pellagra, a constant specific micro-organism is found, 



94 PELLAGRA 

whose characteristics he has described and which he 
has been able to cultivate. He finds it in the blood, 
spinal fluid and organs at death.* [Some discus- 
sion of Tizzoni's work will be found elsewhere.] 
This could be, however, a secondary infection. 

Oidium Lactis. — The harmlessness of Oidium 
lactis is today recognized. However, it always 
accompanies that advanced fermentation of corn in 
which occur those substances which produce con- 
vulsive phenomena, as experiments in the labor- 
atory have demonstrated (Erba and Lombroso.) 
The fermentation of corn by the Oidium lactis gives 
rise to substances which produce a syndrome, having 
much analogy with the paralytic and convulsive 
forms of pellagra, as is shown by the experiments 
of Ottolenghi and Lombroso. 

Cultures in broth of Oidium lactis were scattered over 
the surface of sterilized polenta, which was kept in a moist 
chamber; this polenta was kept six days at 37 degrees. 
Grayish white spots developed on the surface, slightly 
opaque, glistening and having the appearance of colonies of 
Oidium lactis. The seventh day, in the laboratory of Pro- 
fessor Giacosa, an extract of one kilogram of this polenta 
was made with 1,750 grams of distilled alcohol; the 
alcohol was rectified by distilling with tartaric acid ; the 
polenta in a suitable apparatus was put to boil in the alco- 
hol for twelve hours; from this the larger part of the alco- 
hol was separated by filtration, the rest was put on a water 
bath and filtered from time to time to separate the deposit. 
There finally remained a liquid, chestnut brown mass of .70 
grams, of which 1 gram represented 14.28 grams of polenta. 
This material was used in ten experiments by subcutaneous 
injections on frogs, guinea pigs and rabbits. 

*Reale Accademia del Lincei, GCCIII, 1906. 






EXPERIMENTAL RESEARCHES 95 

The lethal dose of this extract was found to be in the case 
of the frog, 14 grams of the extract to the kilogram of 
animal weight; with the guinea pig IS; with the rabbit 33. 
In the case of four frogs, three guinea pigs and one rabbit, 
death occurred with sensory-motor paralysis; the animals 
which survived exhibited paralytic phenomena which later 
slowly disappeared. Tonic cramps were observed in four 
frogs; two died in opisthotonos which persisted even after 
cadaveric rigidity. Upon dissection, was found: premature 
cadaveric rigidity in three frogs and retarded in one rabbit ; 
arrest of the heart in diastole in three guinea pigs and in 
systole in three frogs which had presented tetanic phenom- 
ena. In two frogs there were ecchymoses in the muscles. In 
two others there were bloody infiltrations in the cellular tis- 
sues of the abdomen at the site of the injections; in two 
frogs and in one guinea pig there was effusion of blood in 
the abdominal cavity. 

Bacterium Maedis. 

Numerous experiments have been made with cul- 
tures of the Bacterium maidis of polenta. This 
micro-organism has occupied much of the attention 
of the students of pellagra. However, its identity 
with the potato bacillus, and the fact that it does not 
predominate in the stools of pellagrins ought to 
have led to this conclusion : that its action is indirect 
only and is similar to that of Oidium Lactis in that 
it produces from the parenchyma of the grain toxic 
substances. 

Paltauf made subcutaneous injections in rats, 
guinea pigs and rabbits of young and old gelatine 
cultures of this bacillus and he found that it pro- 
duced results in only one rat which was found ill 
from cysticercus. 



7-P. 



yb PELLAGRA 

After this negative result he made an attempt 
with the alcoholic extract of corn meal, infected with 
this bacillus and left three months at a temperature 
of 35 degrees. He injected this extract into white 
mice in doses of 0.5 c. c. These animals showed 
coma and paralysis with death, at the end of two 
hours. In frogs the injection of 1 c. c. produced 
a state of temporary feebleness. The cultures of the 
potato bacillus in polenta and their extracts gave the 
same results. 

The identity of bacillus maidis and the potato 
bacillus seems, therefore, proven. Heider, with 
Gorizia, has also extracted a substance from spoiled 
corn which gives the reaction of an alkaloid and 
which killed rats with anesthetic and narcotic 
phenomena. 

These experiments were repeated on a larger scale 
by Lombroso, Ottolenghi, Bordoni-Uffreduzzi, and 
their results are given below : 

If cultures on polenta of one, two, six and up to seven 
days old, are given to animals they become accustomed to it 
slowly; the initial diarrhea, which is the only symptom, 
may even cease; the cultures over four to five days old are 
refused, perhaps because of their bad and very pronounced 
taste. 

As a consequence of this nourishment, digestive troubles 
are produced, sometimes vomiting, almost always diarrhea, 
but never derangement of the sensibility or of the motor 
system. At the end of some days the weight begins to 
diminish, but then maintains itself within normal limits. 
The temperature is usually maintained at normal; in the 
first days only two cases showed a slight evening rise. 

The attempt to cultivate this bacillus on wheat bread met 



EXPERIMENTAL RESEARCHES 97 

with little success ; two dogs fed for fourteen days with this 
bread showed no change. 

An experiment was then made with the alcoholic extract 
obtained from a culture on polenta twenty-five days old. 
The extract, prepared by Professor Fileti, was injected into 
three dogs under the skin of the back in doses of 5%, 10% 
and 25% of the weight of the animal. The two dogs 
which had received the largest doses died two days later, 
after presenting the following symptoms : 

Paresis of the hind legs, almost continual tremor, gen- 
eral depression, which was rapid and progressive, gradual 
loss of voluntary motion, complete paralysis of the hind legs, 
mydriasis, slight increase of temperature, acceleration of 
respiration and pulse, insensibility, bloody diarrhea and 
death with prolonged agonistic state. At the autopsy, 
edema of a hemorrhagic nature in the hypogastric region, 
extravasations in the spleen. 

The dog inoculated in the proportion of 5 per cent, of its 
weight exhibited at the beginning the same symptoms, but 
at the end of the second day his condition improved; how- 
ever, the hind legs remained paralyzed and the diarrhea 
continued for several weeks with a remarkable diminution 
of weight. 

In the case of two other dogs, intravenous injections, in 
the proportion of 5 per cent, of body weight caused death 
after the development of the above mentioned symptoms. 

Injections into ten frogs, with corresponding doses, 
brought on death in three hours with paralysis, diffuse 
ecchymoses on the interior of the thighs and in the 
hypogastric region. Intravenous injections of the extract of 
sound polenta up to 10 per cent, had no evil consequences; 
the same may be said of the subcutaneous injections made in 
double doses. 

The bacterium maidis is, therefore, inoffensive 
per se, but releases from corn a ptomaine that has 
a toxic action, eminently paralyzing. 



98 PELLAGRA 

In pellagra, then, we are dealing with an intoxi- . 
cation produced by poisons developed in spoiled com 
through the action of certain micro-organisms in 
themselves harmless to man. [This expresses suc- 
cinctly Lombroso's theory of the cause of pellagra.] 

Since 1883 Lombroso and Peschel have done 
experimental work upon the toxicity of the blood 
of pellagrins as compared with the toxicity of cul- 
tures of bacterium maidis. 

This bacterium is active in decomposing the albu- 
menoid substances and hydrocarbons of corn into 
toxic substances ; perhaps it acts also in an irritating 
manner on the digestive tract. 

The bacterium maidis does not multiply merely in 
the grains and meal of spoiled corn, but also in 
sound corn and in the normal intestine {Bacillus 
mesentericus vulgaris) . 

It is not found in cultures made from the blood 
of grave cases of pellagra. Cuboni sought for it 
in vain in thirty cases of pellagra. Even in the 
erythematous skin and in the viscera of pellagrous 
dogs nothing is found; or, if from their cadavers a 
growth is obtained it is due to putrefactive bacteria. 
When the blood or urine is drawn antiseptically and 
planted, such cultures remain sterile. On the other 
hand, symptoms of pellagra appeared in animals 
that had fed upon the alcoholic extract or the tinct- 
ure of spoiled corn, from the preparation of which 
every microbic element was excluded. 

The injections of cultures of bacterium maidis 
grown on sterilized blood serum, and the injection 
of a culture made from the blood of typhoid pel- 



EXPERIMENTAL RESEARCHES 99 

lagra produced only the febrile disturbances due to 
the pyrogenous substances commonly found in 
almost all such cultures. As often as these experi- 
ments were repeated, the animals on no occasion 
developed symptoms of pellagra, nor of rapid dimin- 
ution of weight, nor of rapid increase of tempera- 
ture; and never any of the cutaneous, muscular and 
nervous symptoms which were met with in dogs fed 
with spoiled corn. 

Some authorities have attributed these febrile 
phenomena to the influence of special micro-organ- 
isms. They have taken these toxic manifestations 
for pellagrous phenomena; and probably having 
obtained, with poor technique, a positive result in 
their cultures, have erroneously concluded that the 
animal was suffering from a true infection. 

But all the pathology of the disease protests 
against any parasitic hypothesis; it is not trans- 
missible by contact and has the greatest analogy 
with alcoholism, which certainly cannot be sus- 
pected of having a microbic origin. 

Moreover, pellagra does not declare itself because 
one may have eaten once or several times of spoiled 
corn; it is necessary to continue the eating of it 
during a certain length of time in order that the 
poison may have its effect. In the case of dogs under 
experiment it was necessary to wait six or seven 
days, often several months, in order to see the first 
true pellagrous manifestations appear. It is for 
this reason that the people of the country and the 
physicians, with some exceptions, have found diffi- 
culty in believing that the disease could come from 
eating spoiled corn. 



100 PELLAGRA 

Nor is there any other parasitic disease, in which 
an amelioration is produced as soon as poor nourish- 
ment is replaced by wholesome food without any 
change in the other conditions of existence. Some- 
thing analogous is seen in the undoubted cases of 
slow poisoning seen in alcoholism, and in the hydrar- 
gyrism of laborers in mercury mines; there the 
symptoms of the disease disappear as soon as the 
introduction of the poison ceases. Infectious diseases 
have, besides, a progressive course, are rarely inter- 
mittent, and are not arrested when the diet is 
changed. Very many of them also show a great 
increase of temperature and have a much more pro- 
nounced tendency to localize themselves in an organ 
or a tissue, which is not the case in pellagra. 

Grain and Meal or Spoiled Corn; and Mouldy 
Corn Bread. 

When in 1883 the corn harvest was spoiled by 
hail and inundation in the districts of Mazze and 
of Vischi, some of it was bought where it was 
grown. It was submitted to botanical examination 
by Professors Gibelli and Mattirolo. The grains 
were found spoiled by the Aspergillus and by the 
Rhizopus, to some extent also by mites and the Bac- 
terium maidis. With this corn and other foods such 
as milk, flour-bread, scraps of meat, bone (to pre- 
vent the objection of inanition), ten dogs were fed 
for from six or eight weeks up to end of life, and 
a larger number of chickens. Here is a resume of 
this series of experiments : 



EXPERIMENTAL RESEARCHES 101 

Weight. In the case of all dogs undergoing the experi- 
ments the weight diminished except in one (a young dog 
which had not attained its full growth). In the other cases 
the diminution commenced at the end of three, four, five, 
six, seven and twelve days. It cannot be said that the 
diminution was due to the exclusive use of the corn, for 
it was less in those which for a time received the corn only, 
and it was more pronounced in those in which milk, white 
bread and bones were given at the same time. 

Temperature. Almost always an elevation of temperature 
showed itself coincident with the diminution of weight — a 
circumstance that demonstrates almost with certainty that 
during the experiment a toxic pyrogenetic substance was 
introduced, analogous to that of the infectious diseases. The 
development of the temperature is a sign still more charac- 
teristic than the diminution of weight, for, during sevea 
months, the weight of the youngest dog increased, while the- 
temperature was constantly elevated. In pellagra, therefore, 
it is not a question of a state of inanition, for in this case 
there would have been diminished temperature. Elevation; 
of temperature is not in most cases the result of the reduc- 
tion of the substance of the body, but of poisons introduce* 
into the organism. Inanition does not come into play, 
for there is often a parallel increase in weight. The eleva- 
tion of the temperature, the appearance of tetanic and 
spastic symptoms, and the frequent appearance of anemia 
(symptoms not peculiar to inanition) prove it abundantly. 

Pulse and Respiration. The pulse and the respiration 
did not show digressions, save in two cases (dogs), in which 
tetanic movements showed themselves and, at the same time, 
sudden interruptions of the respiratory rate, with extreme 
acceleration. 

Anemia. Reduction in red blood cells often shows the 
anemia of the pellagrous, but this anemia it not constant. 
This fact demonstrates that nourishment by spoiled corn 
does not cause chronic inanition, for this produces constantly 
a decrease of red cells. On the contrary, two dogs to which 
bread or broth of moulded corn was always given, showed 



102 PELLAGRA 

an increase of red cells. In one case of sudden death with 
tetanic phenomena, there was no appreciable reduction. 

Musculae Spasms. A symptom, frequent, but not con- 
stant, is the tonic muscular spasm, and the increase of the 
tendon reflexes (with two dogs the tetanic state was very 
pronounced). These cases would appear in their true aspect 
in the light of experiments with the alkaloidal substances 
and with the oil of spoiled corn. The inconstancy of the 
phenomenon is therefore admitted. (In seven cases out of 
ten a complete torpor of the muscles was produced; in six 
cases a cerebral torpor ; in three, loss of sensibility ; in four 
cases out of ten muscular tremors). 

Diabbhea. The most frequent of the complications was 
diarrhea, which was often preceded by refusal of food and 
dysphagia (seven cases), the latter symptom being most 
often due to muscular spasm, and manifested so much more 
frequently than in human pellagra as to make it a special 
characteristic of canine pellagra. 

The Skin. The erythema of the skin was manifested 
only once, completely and certainly, and then in a dog which 
remained free from anemia, torpor and spasmodic phe- 
nomena, and in which the sitophobia and paresis disappeared 
with the appearance of the erythema. The microscopic 
examination of the skin in this case did not, however, 
exclude all idea of a parasitic cause, and threw some light 
on the origin of the erythema by showing proliferation of 
the cellular nuclei and infiltration by plasma cells in the 
deep layers of the skin. 

To sum up, we can say that in dogs pellagra shows 
itself sometimes under the anemic form, sometimes 
under the spasmodic form and sometimes under the 
cerebral form, which is precisely analogous to the 
pathologic anatomy and symptomatology of pellagra 
in man, in whom it is erroneous to speak of pellagra 
in general, and is more didactic than scientific to 
make divisions into first and second stages. A more 




Plate VI. Italian case. Symmetrical, dry, scaly dermatitis of 
hands and forearms. Characteristic facial expression. Cour- 
tesy of W. Bayard Cutting, Jr. 



EXPERIMENTAL RESEARCHES 103 

accurate division would be into anemic, spastic, 
tabetic, cerebral, and other similar forms of pellagra. 

Nutrition with, bread from moulded corn calls forth 
the same symptoms as nutrition with the grain or 
meal of moulded corn. If it never causes true 
tetanic phenomena, it is, however, accompanied by 
rigidity of the lower extremities, with exaggeration 
of the tendon reflexes — symptoms more character- 
istic of pellagra. Later cutaneous erythema, the 
most typical symptom of pellagra, shows itself dis- 
tinctly. This was lacking in other experimental ani- 
mals, although it is known to occur in "enmaiz- 
ados" horses in Mexico, in which it is notable that 
stupidity and dysphagia appear shortly before the 
erythema, and disappear with its advent. And this 
is in wonderful accord with the observations of 
medical practice which tend to establish an antag- 
onism between the nervous phenomena and the skin 
symptoms. Perhaps localized hyperemia acts as a 
cutaneous revulsion — one sees nervous diseases modi- 
fied by the employment of a strong irritation of the 
skin. In general the symptoms are more benign in 
animals fed on mouldy bread. 

In twelve chickens fed on spoiled corn convulsive 
phenomena were exceptionally noted, and if a com- 
plete marasmus could be excluded, the spoiled grain 
alone produced increase of weight, but finally death 
intervened after atrophy of the feather follicles, 
with changes in the skin and horny appendages. A 
fact worthy of remark is that chickens entirely tame 
for months became very wild at the end of five or six 
months on the regimen of corn: they fought their 



104 PELLAGRA 

companions and had to be shut up. Another chicken 
had photophobia and was unwilling to leave the 
cage. 

Taken altogether, the disease was less pronounced 
in the chickens than in the dogs ; however, the chief 
effects of nourishment with spoiled corn, especially 
the cutaneous symptoms and muscular disorders, 
showed results analogous to those of the subcutane- 
ous injections of extracts of oil and of other prepa- 
rations of spoiled corn. 

Tincture of Spoiled Corn. 

The proof seems, then, to be regarded as estab- 
lished, that in pellagra the chronic poisoning does 
not come from microbes infecting the animal 
organism, but from the chemical transformations of 
the parenchyma of corn; and since the more 
important toxic substances pass into the tincture 
made from the grain, it would seem wise and profit- 
able to study experimentally the action of this 
tincture. This would seem all the better since the 
tincture is very well adapted for administration to 
human beings. 

The tincture of corn spoiled by Penicillium glaucum was 
given, for a length of time, to twelve sound and healthy- 
individuals, soldiers and laborers at work in the city, and, 
at the time of the experiment, well fed. Results are given 
below : 

Number 
Symptoms. of Cases. 

Bulimia 9 

Pruritus of back and face 8 

Loss of weight 8 



EXPERIMENTAL RESEARCHES 105 

Urine diminished and of high specific gravity 8 

Diarrhea 6 

Diurnal somnolence 5 

Eructations 5 

Persistent muscular weakness 5 

Desquamations 5 

Headaches 4 

Anorexia 3 

Burning of the eyelids 3 

Repugnance for water 3 

Hyperidrosis 3 

Ephelides on the arms and hands 3 

Palpitation of the heart 3 

Syncope 3 

Variations in the pulse 3 

Increase in weight 2 

Intense thirst 2 

Increase of muscular force 2 

Sensation of heat in head 2 

Sensation of warm water on back 2 

Irritability and emotionalism. . .. 2 

Restlessness at night 2 

Erythemas 2 

Tinnitus aurium 2 

Redness and burning of the skin 2 

Burning of scrotum 1 

Mydriasis 1 

Ptosis 1 

Prickling sensation 1 

Oppression and precardial pains 1 

Vertigo 1 

Furunculosis 1 

Enteralgia 1 

Sensation of foreign body in head 1 

Salty taste 1 

Burning in the throat 1 

No symptoms 2 



1 06 PELLAGRA 

It is worthy of remark that though the experi- 
ments were made on a small number of persons, 
varied symptoms were manifested; in some cases 
heart symptoms developed ; in others skin or nervous 
symptoms; sometimes the symptoms developed late, 
sometimes with astonishing rapidity; some pre- 
sented no symptoms at all. 

At any rate, the proof of the harmfulness of 
spoiled corn as a food appeared from the fact that 
in a few days there was a general loss in weight, 
which varied from 2 up to 7 and even 10 kilograms, 
though some showed an increase of 3 to 4 kilograms. 
In one case this increase may have been due to the 
cure of an old psoriasis ; in another to great hunger, 
which caused the individual to eat more heartily. 

Nervous and cutaneous symptoms showed them- 
selves in some cases after the fifth dose, in others at 
the end of a week, and in some only at the end 
of two months. Two individuals were entirely 
resistive. On the other hand, one robust man showed 
acute poisoning with mydriasis, syncope and profuse 
diarrhea. In another an acute catarrhal condition 
of the stomach was developed. 

Isolated disorders lasted for two and a half 
months after the suspension of the tincture. In one 
case they persisted ten months, but yielded finally to 
arsenic. 

As a happy chance had shown the favorable action 
of this tincture on an old psoriasis, experiments in 
dermatologic therapy were made on forty-five 
patients to whom the tincture, and also the oil which 
is extracted from it, were administered internally 



EXPERIMENTAL RESEARCHES 107 

and externally. In almost all of these cases there 
appeared more or less difficult digestion, nervous 
phenomena and disorders of the cutaneous sensi- 
bility. Improvement in the cutaneous affections was 
pari passu with the appearance of toxic symptoms. 
This, then, would be an example of substitutive 
medication which sometimes cures or relieves certain 
chronic diseases by increasing the vaso-motor tone 
of diseased organs, and in consequence regulating 
trophic influences. 

The principal gastro-intestinal, nervous, and 
cutaneous symptoms resembled those of visceral, 
spinal and ganglionic disease, while there were other 
symptoms evidently cerebral in their nature. 

But the most important result of these experiments 
is the analogy between the symptoms observed and 
the clinical syndrome of pellagra. 

Alcoholic Extract or Pellagrosine. 

To these first experiments must be added others 
made during the course of several years with the 
alcoholic extracts and the oil of spoiled corn, both 
derived from the tincture. These new investigations 
of Lombroso, in collaboration with Dupre, made 
with the glutinous and resinous substances gave no 
results in either man or animals. The toxic sub- 
stance, or pellagrosine, however, given to dogs and 
chickens in doses of 5, 10 and 15 centigrams pro- 
duced droopiness and diarrhea ; in man, torpor, anor- 
exia and nausea, accompanied by diarrhea. 

With very careful preparation one can obtain with 
pellagrosine constantly a toxic action on animals. 



108 PELLAGRA 

Experiments on Frogs : 

In frogs clonic convulsions appeared half an hour after 
the injection of pellagrosine in a strong dose of 50 
centigrams. At the end of an hour there were increased 
motor reflexes and sensible diminution in the cardiac pulsa- 
tions. Two hours later the movements of the heart gradu- 
ally diminished and a tetanic state supervened which 
increased till death. In other experiments it was noted that 
at the end of a quarter hour the frog took a vertical position 
in the water. If placed on its back it did not turn over and 
displayed fibrillary contractions of the lower limbs; at the 
end of a half hour complete narcosis appeared ; after three- 
quarters of an hour anesthesia to the strongest stimuli; 
one hour later tonic convulsions, very much increased reflex 
excitability and a pronounced tetanic state; three hours 
later death. A very small frog after an injection of 5 centi- 
grams died immediately. 

In a great number of experiments there were found very 
notable differences in results, such differences being depen- 
dent upon the size of the dose and the time when the 
substance used had been prepared, whether in August or in 
September. 

With small doses a tetanic state appeared in 90% of the 
cases, especially if the frogs had been placed in lukewarm 
water. Sometimes this state was preceded by paresis or 
perhaps death followed it in half an hour to 25 hours. 

In the case of other frogs with doses of 25 to 100 centi- 
grams tonic cramps appeared in all the cases and paresis 
of the extremities was produced to such an extent that the 
animals rested vertically in the water. In 27 out of 100 
frogs tetanic convulsions, with narcosis, preceded death, 
which occurred usually in thirty minutes. In the cold 
months the substances had scarcely a visible effect and even 
that frequently was evident only on close examination. The 
influence of the temperature appears distinctly when the 
animals are kept under artificial conditions in cold or warm 
water. 

In water at 3 degrees C. a dose of 5 centigrams caused 
only hesitation in movement and increased motor reflexes 



EXPERIMENTAL RESEARCHES 109 

at the end of six to twenty-four hours. The same result is 
produced sooner in water at 8 degrees C. ; at 32 or 36 degrees 
tetanic convulsions with death resulted from even small 
doses; and also from the blood of animals poisoned by pel- 
lagrosine, those injected remained stiff in water at 3 
degrees and could not leap; at 32 to 36 degrees they were 
very lively at first, but soon became somnolent, though they 
did not die and did not show any tetanic condition; they 
succumbed, on the contrary, very quickly with tetanic symp- 
toms, when placed in water at 38 to 42 degrees C. 

For animals kept in lukewarm water the minimum lethal 
dose was 1 centigram per 14 grams of animal weight. The 
maximum dose without death was 50 centigrams per 12 
grams of animal weight. 

Experiments on Birds : 

In general chickens showed a diminished sensibility to the 
effects of the substances. 

In the case of a pigeon death occurred after a dose of 4 
grams per kilogram, with clonic convulsions, preceded by 
narcosis, somnolence and diminution of temperature. The 
blood of this pigeon, still warm, injected into a frog, pro- 
duced tetanic symptoms. In the case of hawks death 
occurred after a dose of 2 grams per kilogram, with 
diminution of weight, narcosis and tonic-clonic convulsions. 

Experiments on Rodents: 

In case of rats doses of 12 grams per kilogram given 
internally remained without results ; on the other hand, the 
same dose administered subcutaneously produced torpor, 
anorexia and paralysis of the hind legs with unilateral con- 
tractions ; they fell on the right side and when they tried to 
move they rolled or sometimes walked backwards. Later 
complete paralysis and notable diminution of temperature. 
Convulsions appeared in only two rats after the absorption 
of 2.8 grams per kilogram of the poison. In three others 
with somewhat larger doses, death occurred at the end of 
one to thirteen hours. 



110 PELLAGRA 

The autopsy showed hyperemia of the spinal cord, pia 
mater, liver and kidneys, once also of the lungs ; in one case 
softening of the cord was found. In the case of guinea pigs 
the minimum lethal dose was 2 grams per kilogram, but 
death did not occur until twelve hours later. In the case 
of three out of six of these animals tetanic convulsions 
appeared, preceded or followed by paralysis. Heat seemed 
to favor narcotic, as cold did tetanic phenomena. 

Experiments Upon Cats : 

An experiment made upon one adult cat only with a sub- 
cutaneous dose of 1.4 grams per kilogram of the most active 
preparation caused death in ten hours. Soon after the 
injection immobility set in with refusal of food and rigidity 
of the hind legs. It was only at the end of .three hours that 
there appeared tremor, then tetanic convulsions, hyper- 
esthesia, increase of temperature (2 degrees) and, two hours 
later, coma. At the autopsy — hyperemia of the brain, spinal 
cord, liver and kidneys. 

Experiments on Dogs : 

In cases of dogs the results were also convincing. With 
doses of 2 grams per kilogram repeated vomiting occurred 
after a half hour to two hours, also contraction of the hind 
legs, dilated but mobile pupils, increase of sensibility and 
of motor reflexes — two hours later general tetanic convul- 
sions, acceleration of the pulse and respiration and lowering 
of temperature. After each attack of tetanic convulsions the 
dog loses his equilibrium, crouches on the hind quarters and 
presses his head and paws against the ground. Experiments 
with other dogs gave similar results. 

At the autopsy there was found hyperemia of the men- 
inges, optic thalamus and of the gray matter of the spinal 
cord; in one case softening of the lumbar cord; twice 
ecchymoses of the lungs and congestion of the liver; once 
only hyperemia of the entire brain. 



EXPERIMENTAL RESEARCHES 



111 



The following table is a resume of the experiments show- 
ing lethal doses : 



In case of 



Minimum of 
grams to the 

kilogram 
of body weight 





Average time 
of death in 
hours 



Frogs. . 
Cats. . , 
Pigeons. 
Hawks . 
Rats. . 
Rabbits. 
Guinea Pigs 
Dogs. . . . 



6 

14 
5 
3 

5.4 
2.3 
1.2 

11 



Oil Extracted from Spoiled Corn. 

It is necessary to distinguish three different prepa- 
rations made from the oleo-resin of spoiled corn: 
that of July and August which is very bitter, 
muddy, chocolate colored, with a strong smell, ob- 
tained from corn carried to the state of putrid 
fermentation ; the oil of September, less colored, less 
bitter and having a normal odor, is extracted from 
corn less spoiled; finally, the oil extracted from 
yellow bread, which is solid at 19 degrees C, and 
the oil extracted from the embryos of the grain. 

Experiments on Fbogs : 

It was found in more than a hundred cases that in experi- 
ments made during summer with the active preparations 
tetanic convulsions appeared at the end of four to ten hours 
in 50 per cent, of them. The dose of the preparation was .75 
gram up to 1 gram with animals which weighed between 
18 and 35 grams. To tetanic convulsions succeeded paralysis 



8— p. 



112 PELLAGRA 

of the hind legs in 5 per cent., narcosis in 10 per cent. ; in 30 
per cent, tetanic convulsions did not occur, but difficulty in 
leaping and exaggeration of the reflexes of the hind legs at 
first and later of the fore legs occurred. In 20 per cent, 
only narcosis occurred without spasmodic symptoms, but 
death always followed. 

The same preparation, in dose of 1 gram for 23 grams 
of weight, injected into frogs kept in a room at 8 degrees G. 
in December, produced only mild and retarded symptoms. 
Tetanic phenomena showed themselves at the end of eighteen 
hours, and at the end of thirty hours death occurred. Other 
experiments in cold or warm water demonstrated that the 
symptoms of poisoning were much mitigated by cold. 

If, before the injection, the heart was laid bare, there was 
found, as in the use of the alcoholic extract, that at the end 
of a half hour a retardation of the pulse occurred most 
marked on the appearance of tetanic phenomena. 

The same tetanic phenomena appeared after injection was 
made in a rat whose brain had been removed ; partial section 
of the cord prevented spasmodic phenomena on the corre- 
sponding side. The members remaining in nervous connec- 
tion with the rest of the body, but not with the circulation, 
exhibited constantly tetanic symptoms. 

The urine and blood of animals having had injections of 
the alcoholic extract as well as the oil, produced tetanic 
phenomena in frogs, though the animals themselves remained 
free from toxic symptoms. 

Experiments on Chickens : 

These experiments are important because of their dura- 
tion. In one chicken with a subcutaneous injection of the 
oil there were no motor symptoms ; but it was droopy all day 
and had diarrhea. A cock behaved in the same manner. 
When given by the mouth, this substance had a less marked 
effect; however, it arrested increase in weight in young 
fowls. In one untreated chicken the weight increased 200 
grams from the 20th of November to the 2nd of December, 
but under treatment with the oil from the 3rd to the 16th 
of December the increase of weight was only 100 grams. 



EXPERIMENTAL RESEARCHES 113 

Finally, after five months of interrupted administration of 
the oil, there appeared choreiform movements of the head, 
previously observed in the experiments with Dupre. In the 
case of one chicken choreiform movements of the head ap- 
peared at the end of ten days ; with repeated doses the motor 
derangement became general — it walked backwards, raised 
the feet slowly and in an exaggerated manner, and had a 
tendency to walk very near the wall. Then eczema of the 
comb appeared with diarrhea, increase of temperature after 
the injection, defervescence in the intervals ; the chicken died 
with typhoid and paralytic phenomena. At the autopsy were 
found intestinal hemorrhages similar to those seen in septic 
poisoning. 

Experiments on Mammals : 

With four rats one dose of 5 grams brought about 
subnormal temperature with paresis, contractures, and once 
death following paralysis of the hind legs. A cat, after a dose 
of 4.9 grams per kilogram, had photophobia and refused 
food. With larger doses (6 gr.) loss of appetite, paresis, 
decided photophobia and death at the end of two days, with 
loss of 40 per cent, in weight. 

In the case of a bitch, after an injection of 20 grams, tonic 
convulsions of the legs and paresis occurred in two hours. 
Three hours afterwards there remained only a decided reflex 
excitability, mydriasis, agitation, refusal of food and stag- 
gering gait. The next day there remained only difficulty in 
leaping, and walking with rigidity of the fore legs. In 
another dog, after an injection of 30 grams, torpor, rigidity 
of the hind legs and slight desire for food. In general, the 
oil produced the same symptoms as the alcoholic extract, 
although less in degree. 

Oil Extracted from Moulded Bread. 
The oil of moulded bread produced the same 
symptoms as the maximum grade of oil of corn pre- 
pared in August. In a single experiment it was 
more active. 



114 pellagra 

Extract of the Embryos of Spoiled Corn. 

This oil, or rather fat, produced symptoms similar 
to those produced by oil made from the entire grain, 
but larger doses were required. 

Oxidized Oil of Corn. 

The rancid oil of corn has produced various 
results, physiological and toxic; these results have 
been confirmed by the investigations of Bim; they 
are: diminution of weight and increase of tempera- 
ture. In frogs temporary torpor was produced with 
an injection of 2 grams. The effects are variable 
according to the quality of the corn used in making 
the oil. Control experiments have been made by 
injections of olive oil and oil from fresh and sound 
corn. The results were negative. 

Aqueous Extract of Spoiled Corn. 

The aqueous extract has an antifermentative 
action analogous to that of the alcoholic extract, 
though more feeble. The effects on the animal 
organism are also less intense. 

In frogs, after large doses (70 to 75 centigrams) were 
injected, there appeared paralysis of the hind legs, generally- 
temporary, fibrillary twitchings, narcosis and death at the 
end of three-quarters of an hour. A smaller dose (30 centi- 
grams) produced the same symptoms, but required a longer 
time. At the end of three hours fibrillary twitchings set in, 
then paresis and at the end of six hours death. 

Diminution of the cardiac pulsations is noted one-quarter 
hour after injections. Doses of 5 grams per kilogram to 



EXPERIMENTAL RESEARCHES 115 

cats produced vomiting, narcosis and loss of weight. After 
doses of 8 grams per kilogram death at the end of a half- 
hour, preceded by clonic and tonic convulsions. 

At the autopsy was found hyperemia of the liver 
with fatty degeneration of the kidneys, once hyperemia of 
the base of the brain and ecchymoses of the lungs. 

In the case of five dogs the symptoms were almost identi- 
cal. By mouth no effect was noted till the dose of 8 grams per 
kilogram was reached, when narcosis and tremor appeared. 
Subcutaneous injections always produced abscesses ; in doses 
of 5 grams per kilogram death occurred in fourteen hours. 

In brief, the symptoms preceding death, especially the 
nervous symptoms, were, in four dogs out of five, identical 
with those produced by the alcoholic extract. In one of the 
dogs loss of intelligence was preceded by deafness; twice 
erection was produced. The five dogs held the hind legs 
apart, refused food, and had a reduction of temperature from 
two to eight degrees. 

The autopsy showed twice extravasation at the base of the 
brain, hyperemia of the spinal cord, principally of the gray 
matter, and congestion of the stomach and liver. 

Alkaloid of Spoiled Corn. 

The alkaloid, analogous to strychnine, extracted 
from the oil by Erba, was injected in a dose of 2 
milligrams into frogs; tetanic convulsions appeared 
in twenty to thirty minutes. On the other hand, 
the rate of cardiac pulsations did not diminish 
as much as in the experiments with other substances, 
perhaps owing to the more rapid action of the 
poison. The alkaloid taken directly from bread of 
spoiled corn killed a frog with tetanic symptoms in 
forty minutes in dose of .0025 grams. After 
the extraction of the alkaloid the residue is still 
poisonous in small doses — a thing which proves that 



116 PELLAGRA 

the isolated alkaloid is not the only poisonous sub- 
stance of corn. 

Extracts of Ordinary Corn. 

Pellizzi has made a number of experiments, bac- 
teriologic, chemical and toxicologic, which confirm 
the preceding. [A number of workers have con- 
firmed Lombroso's experimental work in a general 
way, such as Erba, Hausemann, Pellogio, Gosio and 
Ferrati, Mariani, Belmondo, Tirelli and Babes and 
Sion.] He isolated numerous micro-organisms from 
corn meal more or less spoiled, and he concluded that 
the development of numerous colonies of diverse 
bacteria can be prevented only by drying the corn 
in ovens heated to 70 degrees C. for several days 
before being ground. Some meals, having all the 
appearance of originating from good corn and show- 
ing a bright surface like that which has been dried 
a long time, contained often more bacteria than other 
meals which had appeared to be spoiled. The appar- 
ently sound meals were, therefore, notwithstanding 
appearances, just as spoiled and dangerous as those 
more clearly damaged. Pellizzi prepared toxines of 
sterilized cultures of these micro-organisms for sub- 
cutaneous and intravenous injections into rabbits 
and dogs. Sometimes he employed pure bouillon 
cultures, at other times mixed. Certain cultures, 
such as those of diverse hyphomycetes, the saccha- 
romyces sphaericus albus and of the bacillus subtilis, 
did not cause particular derangements ; the bacterium 
maidis produced results similar to those obtained by 
others who had worked with it; preparations made, 



EXPERIMENTAL. RESEARCHES 117 

however, from cultures of micro-organisms allied to 
the putrefactive bacteria produced, chiefly in dogs, 
phenomena analogous to pellagrous poisoning in 
man. 

The results of this work seem to show that the 
important bacteria of spoiled corn resemble the 
putrefactive bacteria and that bouillon cultures of 
them contain only organic nitrogenous substances in 
decomposition. The results could then be attributed 
exclusively to putrid substances and not to a specific 
poison of spoiled corn. 

Pellizzi, therefore, did not continue his researches 
with these cultures, but with the aqueous extracts 
made from polenta and from corn bread prepared 
from meal bought in the stores which furnish the 
tables of the people. Examined bacteriologically this; 
meal contained numerous putrefactive bacteria such 
as are found in spoiled corn. As a control experiment 
aqueous extracts of wheat and of rye bread were 
used, but without results. 

Extracts of polenta and of corn bread were placed 
for eight hours in a damp chamber; examination 
revealed the presence of numerous forms of micro- 
organisms of corn. 

The effect of these preparations was tried on dogs 
by the mouth, subcutaneously and intravenously. 
The most interesting results, which we shall abridge 
here for want of space, were from intravenous injec- 
tions. If injections are made intravenously into an 
animal, in a dose of 10 grams per kilogram of 
weight, of aqueous extract of a polenta meal con- 
taminated bacteriologically, but still edible, one pro- 



118 PELLAGRA 

duces, especially in dogs, grave pellagrous manifes- 
tations: paresis, gastro-intestinal disorders, psychic 
confusion. The same extracts made from materials 
previously placed for six hours in a Koch sterilizer 
become inoffensive. 

It is evident from all of the experimental work 
that constant and characteristic effects have been 
obtained by the use of extracts of spoiled corn, or of 
its products. 

The facts recognized by statistics and by clinical 
observation are not always easy to reconcile. The 
statistics show that only in the case of 25 per cent, of 
pellagrins can it be affirmed with certainty that they 
were nourished with food consisting principally of 
corn very badly spoiled. On the other hand, clinical 
observations demonstrate that it is not rare to see 
cases of severe pellagra in persons well nourished 
and in good circumstances, of whom it can be said 
that they do not habitually eat spoiled corn. Finally, 
there are recrudescences of pellagra with grave 
symptoms when the convalescents return to nourish- 
ment with corn, even when the corn consumed 
answers to the most severe hygienic demands. 

These experiments prove the existence of micro- 
organisms either in a developed form or in the form 
of spores in the grain and meal of corn which have 
the very best appearances and are habitually used 
for human food. It can then be supposed that the 
elements necessary to the production of the pella- 
grous symptoms, once having entered into the circu- 
lation, are there decomposed under the action of 
ferments found in the organism, and undergo, after 




Plate VII. South Carolina case. "Wet" dermatitis. Localization 
unusual. Hands edematous. Cachectic stage. 



EXPERIMENTAL RESEARCHES 119 

absorption, toxic transformations. It cannot be 
determined, according to Pellizzi, what is the nature, 
in a given medium, of the products of the bacteria 
found on corn. Do they constitute a chemical poison 
in the strict sense of the word; or, as is more prob- 
able, do they belong to the amorphous chemical fer- 
ments, which can be produced at a determined phase 
of their development? For many similar ferments 
complex actions have been found; Pellizzi found 
them in his extracts of corn. It is reasonable that 
the harmful effect does not come from a pure culture 
of one organism, but from a mixed culture of 
several varieties. It is a question, certainly, of a 
combined and probably mutual action, not yet 
defined. If a toxic substance could be directly drawn 
from edible corn without mixture with putrid 
substances in the strict sense of the word — then the 
features of pellagrous poisoning can represent a 
polytoxic state. Finally, it is necessary to take into 
consideration the most complex and various facts 
and to give to spoiled corn a very wide definition. 
Almost all corn, with very few exceptions, can thus 
be considered spoiled corn to some degree. Corn, 
absolutely sterilized, if one could have it, would 
certainly be harmless, and of course the meal also. 
But if it is difficult to have corn entirely dry, it is 
certainly impossible to keep it in this state, for as 
soon as the places in which it is stored reach a cer- 
tain degree of humidity, the most diverse micro- 
organisms find favorable conditions for their devel- 
opment. 



120 PELLAGRA 

In concluding his experimental work Lombroso 
states that "with such evidence as has been submitted 
it does not seem longer possible that the specific 
cause of pellagra can be doubted, and it is certain 
that the etiology of other maladies can present docu- 
ments neither more numerous nor more convincing." 

[The author has necessarily given to a large extent 
only Professor Lombroso's ideas on the etiology of 
pellagra, and Lombroso's labors in this field entitle 
his ideas and opinions to the highest admiration and 
respect. He has, he tells us, spent more than twenty- 
five years of his life at it, and that these years have 
not been fruitless is abundantly witnessed wherever 
the disease has perplexed and taxed the medical man 
and the sanitarian. His scientific work is of a high 
order and his hypothesis as to the etiology of pel- 
lagra has had a profound effect not only in purely 
scientific fields but also has resulted in great organ- 
ized endeavors to limit and eradicate a disease which 
has been a burden on Italy for a long period of 
years. 

Notwithstanding this, there are other important 
ideas on the etiology of pellagra which should 
receive some consideration. The subject is by no 
means a closed one. And it would seem wise that 
the American reader, to whom the subject is to some 
extent new and unfamiliar, should get a general 
view of the etiological field. 

A recent Italian writer has said: "The actual 
knowledge of the cause and nature of pellagra, one 
may say, remains still in the realm of hypothesis, 
although an extraordinary scientific activity on the 



ETIOLOGY 121 

part of students, especially Italian students, has 
thrown light on many important points." That is 
to say that in any definite scientific sense the etiology 
of pellagra is still essentially unknown. This, how- 
ever, is very far from saying that nothing is known 
of its etiology. There is, on the contrary, a profound 
and general conviction, among students and author- 
ities, that between pellagra and the use of Indian 
corn as food there exists some definite, etiological 
relation, the ultimate nature of which, however, still 
remains in doubt. With the exception of a small 
group of students, to whom reference is made later, 
practically all theories of etiology take into essential 
consideration the use of corn or its products as a 
food. 

This idea of a causal relation between corn and 
pellagra is almost as old as the history of the dis- 
ease itself, and such a suspicion is thought possibly 
to have been entertained even by Casal himself, as 
has been noted previously. Indeed, there are authors 
who are inclined to maintain that the disease was 
known before Casal's day and that even then similar 
suspicions were entertained. It was perhaps first 
formulated by Marzari (1810), who believed that 
corn caused the disease by reason of its deficiency in 
certain nutritive qualities. And with this early 
declaration very soon came into existence the great 
corn theory of pellagra, and the ultimate creation of 
the so-called "Zeist" (from Zea Mays) and "Anti- 
zeist" schools of thought. Between these opposing 
schools a wordy war was waged for many years 
and echoes of it still linger, but from that time 



122 PET J, AGRA 

till now the corn idea, in one form or another, has 
held the dominant place in the etiology of pellagra. 

Following its definite enunciation, the corn doc- 
trine, more or less rapidly, began to undergo a 
development and modification which has continued 
up to the present time with a consequent almost 
bewildering variety of opinions. 

The first and one of the most important steps in 
its evolution was the announcement of Balardini's 
"Verderame" theory. Balardini had noticed on the 
grain a greenish discoloration (hence "Verderame") 
which was found later to be due to the growth of a 
mould, Sporosorum maidis; and he conceived the 
disease to be due to this mould. This introduced an 
entirely new phase of the corn theory in attributing 
the disease not to corn per se, but to spoiled or 
damaged corn. Later, Lombroso, doubtless under 
the stimulation of Balardini's work, took up this 
idea and developed it broadly, creating ultimately 
what is sometimes called the "Zeitoxic" school, who 
maintain that not in corn, but in spoiled corn, must 
the cause of pellagra be sought. 

Without attempting to trace historically the evo- 
lution of the corn doctrine, it will perhaps serve 
every purpose to state, somewhat briefly perhaps, 
the important etiological views held on the subject 
by students of the disease. In the preceding pages 
Marie has given somewhat at length the general 
character of the evidence on which is based the broad 
idea of an etiological relation between corn and pel- 
lagra, so that need not detain us longer. 



ETIOLOGY 123 

Now, disregarding some of the fine and unim- 
portant distinctions, we may place the various mod- 
ifications of the corn theory into a few general 
groups, some of which may be dismissed with very 
few words. 

1. The idea that corn, as a food stuff, is wanting in 
proper nutritive value. This conception, at one 
time of rather wide importance, had finally to be 
abandoned when it was shown by careful analysis 
that this cereal possesses high nutritive value, is rich 
in fats and nitrogenous substances and easily assim- 
ilable (further reference is made to this in Chapter 
IX). It is also to be noted that not infrequently 
pellagra is found among well-nourished individuals 
and its early symptoms are not those of inanition. 

2. The idea that good sound maize contains certain 
toxic substances which cause pellagra. This idea 
also was discredited by the absence of pellagra in 
many places where corn for long periods of time 
had been extensively used as food. 

It is worth while to note here, however, the impor- 
tant fact that the gross distinction between sound 
and spoiled corn is, in the opinion of many able 
observers, by no means always easily determined. 
The grain by reason of its rather poorly protected 
embryo and its high fat and nitrogen content readily 
undergoes change under the influence of bacterial 
growth. Pellizzi and Tirelli, after an extensive exper- 
imental research, divided spoiled corn into three 
classes: (a) corn evidently and profoundly altered; 
(b) corn apparently little altered; (c) corn appar- 
ently normal. These changes in corn take place all 



124 PELLAGRA 

the more readily, of course, in the presence of 
moisture; hence the importance of properly curing 
and storing the grain. 

3. The toxicochemical idea that corn by reason of 
parasitic growths (bacteria or moulds) may undergo 
change with the formation of one or more toxic 
substances of a chemical nature (exogenous poisons) . 
In other words, instead of an infection of the body 
with the elaboration of toxines within the organism, 
we have, so to speak, an infection of the corn with 
elaboration of toxines outside of the body, which are 
toxines nevertheless and when introduced into the 
organism produce their characteristic effects, though 
the bacteria which produce them may be in them- 
selves harmless to man. 

This is the great and important Lombrosian idea 
and has been fully discussed in other places. It has 
had a profound effect on the problem of pellagra, 
and has attracted a host of adherents. 

It is only fair to say here, however, that the experi- 
mental work of Lombroso and others has not escaped 
criticism at the hands of many earnest and capable 
men. There are not a few who think that such 
experimental evidence is inconclusive, and that the 
disease picture reproduced in animals, and even in 
man, while it may be similar to pellagra, is not neces- 
sarily the disease itself; and that such poisons are 
not as yet clearly shown to be specific. For example, 
Gosio, in reviewing the subject of etiology recently, 
said: "Indubitably the various toxic moulds of 
corn have the power of producing a form of pois- 
oning, which has many points of contact with 



ETIOLOGY 125 

pellagra; but if this be in reality pellagra or such 
pellagra as is observed in practice, if the syndrome 
which happens to be reproduced in animals by 
poisons of moulds represents without doubt the 
specific pellagra of man, it yet remains rigidly to be 
demonstrated." And again he says: "Always, 
however, one speaks of a proof which does not make 
a break in the true nucleus of the problem, which is 
the demonstration of the chemical identity between 
poisons circulating in the blood of a pellagrin and 
the poisons of moulds." 

It is of great interest in this connection to know 
that Babes and Manicatide, as well as Antonini and 
Mariani, have, from a series of careful experiments, 
concluded that there exists in the blood of cured pel- 
lagrins a specific antitoxic power against the poisons 
of spoiled corn. 

4. The toxicoinfective idea that from spoiled corn 
there is formed within the body certain toxic sub- 
stances (endogenous toxines). With this view the 
disease becomes in reality a form of auto-intoxica- 
tion, or perhaps an intestinal mycosis. 

Neusser, for example, in certain cases advocated 
the idea that there is formed in corn, largely by 
the Bacterium maidis, a certain "receptive mother 
substance" which later in the gastro-intestinal tract 
underwent a further change and so became toxic; 
and De Giaxa, as well as Di Donna, have laid stress 
on the importance of the colon bacillus, supporting 
the idea that the vegetating properties of this bacil- 
lus may become greatly modified on a culture 
medium of corn, with the consequent production in 



126 PELLAGRA 

the intestinal tract of specific substances. Marie, as 
we have seen, also seems to favor to a certain extent 
a possible idea of autointoxication. 

5. The idea that pellagra is a specific infection, 
either by moulds or by bacteria, derived from corn, 
or usually derived from that cereal. 

The flora of corn, as we have seen, has received a 
great deal of attention, and it is needless again to 
refer at length to that here. There remains, how- 
ever, the more or less recent work of two men which 
seems of sufficient importance to justify notice. 
These are Ceni and Tizzoni. 

In 1902 Ceni declared pellagra to be due to an 
infection by two moulds, Aspergillus fumigatus and 
flavescens — a true aspergillosis; or a "toxico-para- 
sitic" disease. 

Ceni has written quite extensively on the subject 
and his work has attracted a great deal of attention. 
His conclusions are based on elaborate and carefully 
conducted experiments on animals, the details of 
which can not be given here. 

It has seemed to many that with his ideas at last 
some adequate explanation of the real nature of 
the malady may ultimately be achieved. The essen- 
tial parts of this hypothesis will serve to show the 
reader its scope. It is a significant fact, however, 
that his work has not yet been confirmed. 

Ceni states that individuals who die with the 
characteristic phenomena of pellagra, either in the 
acute or subacute forms, succumb almost always as 
a consequence of an aspergillary infection ; and that 
this infection, localized generally in the lungs, 



ETIOLOGY 127 

pleurae, pericardium, pia mater, or mesenteric glands 
contributes the determining cause of the morbid 
phenomena exhibited by the sufferer. 

The pathogenic agents of this infection are repre- 
sented especially by the Aspergillus fumigatus and 
the Aspergillus flavescens, which usually act each by 
itself and rarely together in one infection. 

These parasites, ingested with food, pass through 
the intestinal wall in the state of a spore, and, as 
such, localize in the various organs or tissues. 
Locally they set up a true inflammatory process, 
and they elaborate very virulent poisons which give 
rise to the general intoxication. 

The gravity of these morbid phenomena is in 
direct ratio with the pathogenic power of the two 
species and the state of their virulence, which latter 
seems to depend on the season of the year. The 
Aspergillus fumigatus appears to be the more path- 
ogenic of the two, and its state of virulence is greatly 
heightened in the spring months, while the Asper- 
gillus flavescens displays its greatest poisonous 
properties in the fall. In both cases this season 
corresponds to the "cycle of the annual biologic evo- 
lution" of the two moulds, and it will be noted that 
this heightened virulence corresponds also to the 
seasons when pellagra shows its most severe and 
characteristic symptoms in man. 

Regarding the relation of these pathogenic moulds 
to corn, Ceni states that food prepared from corn 
which is infected by these parasites, constitutes a 
direct cause (concausa) along with the moulds, the 
corn thus serving as a means of infecting man by 

9- p. 



128 PELLAGRA 

way of the intestinal tract. And further that food 
infection by these micro-organisms is in direct ratio 
to the unhygienic surroundings in which such food 
is prepared or stored. His idea seems to be that 
while corn may not be absolutely necessary as a 
means of conveying this infection it is neverthe- 
less in all probability a very important and general 
method of doing so, at least in Italy. And further- 
more that corn is a particularly favorable medium 
and the parasites which develop on it and are eaten 
with it seem to possess a virulence much more exalted 
than others which grow on other substances. 

Not only in these moulds but in other varieties of 
Aspergilli and Penicillia virulent and characteristic 
toxines have been found and such moulds are 
regarded as pathogenic, but the Aspergillus fumi- 
gatus and flavescens alone seem to possess the power 
of invading and infecting the body. All other 
varieties appear to elaborate their toxines in the 
intestinal tract and so poison the organism from this 
place. 

Ceni has also declared that in all pathogenic 
moulds the season of the year plays the same impor- 
tant part as in Aspergillus fumigatus and -flavescens; 
and the micro-organisms are most virulent at the 
culminating phase of their development. Moreover, 
the various moulds or their varieties produce often 
toxines quite different in character. For example, 
there seem to be two varieties of Penicillium 
glaucum, one variety A, and another B. The A 
variety produces characteristic depressive phe- 
nomena (general depression, muscular relaxation 



ETIOLOGY 129 

with diminution of tone, etc.), while the B variety, 
on the other hand, gives rise to exciting symptoms 
(exaggeration of reflexes, general tremor, spasmodic 
state of musculature, etc.). 

Finally, these moulds seem able to withstand quite 
high temperatures, a fact of importance in connec- 
tion with the usual cooking of corn before its con- 
sumption. 

It may be added that Ceni's statements with 
regard to seasonal virulence of moulds hold good for 
the Italian climate in which he did his work. Cli- 
matic conditions in this respect seem to exercise 
much influence and should be taken into considera- 
tion. 

Tizzoni also considers pellagra an infection, but a 
bacterial and not a mould infection — the specific 
micro-organism is called the Strepto-bacillus pel- 
lagrae. 

It is a small, short bacillus generally, but seems 
to be somewhat irregular in its form, grows in long 
or short chains or groups, colors well with the usual 
aniline dyes, often showing polar staining. It does 
not form spores, and grows best at 37 degrees C. on 
human or rabbit blood agar, but is said to resist a 
temperature of 80 degrees or even 90 degrees for one 
hour. 

There seem to be two different, distinct strains or 
types of the micro-organism, readily distinguished 
by cultural methods. One of them corresponds to 
the acute phenomena of pellagra and the other to the 
more chronic states. The bacillus is pathogenic for 
the usual laboratory animals, but is most character- 



130 PELLAGRA 

istic in the guinea pig; and its toxines show a long 
period of latency. 

This organism was first isolated from the blood 
and organs of acute pellagrins, but later (1909) also 
from the stools and blood of chronic pellagrins, as 
well as from spoiled corn. 

In feeding experiments on animals the morbid 
picture of pellagra was reproduced distinctly in the 
guinea pig, but only when a liberal share of corn 
was added to the food of the animal. 

The infection then is derived from spoiled corn. 
The elective lesion is in the intestine which is always 
primarily involved. This intestinal lesion is always 
followed by a specific, general intoxication which is 
especially manifested upon the nervous system, the 
blood vessels and the red blood cells; and second- 
arily upon the liver and kidneys. The toxines are 
said to have a particular affinity for the nervous 
system, conducing ultimately to its profound dis- 
integration. 

This micro-organism may, as Marie has suggested, 
be only a secondary invader. Tizzoni's completed 
work is too recent to have received much critical 
notice as yet. 

In our work we have been unable to isolate this 
micro-organism after repeated trials. In fact, all 
cultural methods with both blood and spinal fluid 
have with us been negative, nor have we had better 
success with animals. 

So much for the maize theory and its variations. 
Now when we turn to the "antizeists" we find them 
greatly in the minority. There are two great facts 



ETIOLOGY 131 

which have been urged against the corn theory. 
First, and most significant, is the extensive territory 
over which corn is, and has been cultivated and 
used as food for many generations, and yet no pella- 
gra has appeared. The second is the frequently 
reported cases of pellagra in which there is no his- 
tory of the use of corn or its products as food by the 
sufferers from pellagra. 

The first statement is of course evident, and the 
"zeitoxic" idea is offered in explanation. The sec- 
ond is by no means always admitted, and has proved 
the cause of much controversy. Soon after its cre- 
ation the "zeist" idea met with much opposition, and 
later a group of French thinkers, led by Lan- 
douzy and others, reported a number of cases of 
pellagra where no corn had been consumed. Roussel, 
the able and ardent French "zeist," sharply 
questioned such observations and rather effect- 
ually discredited the diagnosis, introducing at 
the same time into the literature of pellagra the 
now well known term pseudopellagra, which he 
thought described their cases, as they did not con- 
form to the picture of the true disease. This term, 
pseudopellagra, has itself been the cause of confu- 
sion to some and an object of ridicule to others. 
Manson speaks of the invention of the comfortable 
term pseudopellagra, and scornfully remarks : "The 
disease is pellagra when it fits in with the orthodox 
theory and when it can be connected in any way 
with maize, but when this is not possible, the disease 
becomes pseudopellagra." 



132 PELLAGRA 

From France frequent reports have been and are 
being made of pellagra without corn, and there 
has grown up there a school of thought which 
denies that pellagra is a morbid entity at all. It is 
spoken of as the pellagrous syndrome and regarded 
as a morbus miseries. It is undoubtedly true that 
there may arise among alcoholics and in cachectic 
states, especially among the insane, certain symptoms 
simulating in many respects pellagra, yet such a 
diagnosis is not admissible; and it is said that a 
careful study of such cases readily permits discrim- 
ination. Certainly it seems difficult to understand 
how doubt can arise that pellagra is a disease sui 
generis, when consideration is given to its unique 
symptomatology, its anatomical lesions, epidemi- 
ology, and geographical distribution. 

All criticism of the maize school, however, is not 
of this destructive type. At the meeting of the 
British Medical Association in 1905, Sambon, in a 
notable paper, put forward the highly interesting 
suggestion that pellagra might be due to some 
protozoon, a suggestion which has later met with 
the hearty approval of Manson. The general line 
of this argument is that an examination of the 
numerous observations and experiments shows one 
fact clearly, and that is that each investigator asserts 
that he has produced pellagra, either in man or 
animals, and yet it is evident that the disease can 
have but one cause. It is unwise, therefore, to place 
too much reliance on such experiments, and it should 
not be forgotten, as history amply shows, that the 
interpretation of experiments is often as fallacious 



ETIOLOGY 133 

as the interpretation of natural facts. The reputed 
historical facts with regard to the relation between 
the introduction of corn culture and the appearance 
of pellagra are called in question, and an attempt is 
made to show that there is historical evidence to 
prove that corn was grown in Europe long before 
the date usually assigned. It is pointed out that 
the areas of corn growing and pellagra endemicity 
do not coincide, that pellagra has been observed fre- 
quently in parts of France, Spain, and Italy where 
corn is not cultivated, and that the comparative 
study of the distribution and prevalence of pellagra 
at different periods is decidedly unfavorable to the 
corn theory. 

The opinion is expressed that the prevailing ideas 
as to the etiology of pellagra are very unsatisfac- 
tory, and that the corn idea has been much too 
dogmatically adhered to by investigators. The sug- 
gestion is made that pellagra shows many analogies 
with such diseases as syphilis, trypanosomiasis, and 
kala azar. Such remarkable resemblances are noted 
between pellagra and trypanosomiasis as the char- 
acteristic, perivascular, small cell infiltration, benefit 
by treatment with arsenical preparations, and the 
mononuclear increase in the blood. It is further 
suggested that the parasite may be insect borne, and 
the erythema of pellagra may be one of those inter- 
esting instances of correlation in nature whereby 
the parasite is enabled to enter some intermediate 
host, complete its life cycle, and perpetuate its exist- 
ence, such as is seen in the correlation between the 
night swarming of the larvae of certain filaria and 



134 PELLAGRA 

the nocturnal habits of its intermediate host, the 
mosquito; and that corn may perhaps be found to 
sustain some such relation to the etiology of pellagra 
as the swamp has been shown to sustain to the 
etiology of malaria. 

In this connection it is highly interesting to 
record that Babes and others in a very recent article 
have reported highly beneficial effects in the treat- 
ment of pellagra by atoxyl and arsenous acid com- 
bined, and they have put forward practically the 
same suggestive idea as Sambon's. They state that 
the almost specific therapeutic action of arsenical 
preparations as well on certain protozoal diseases 
as upon the manifestations of pellagra at least sug- 
gests, by analogy, some conclusions as to a similar 
etiology. Pellagra, they still think, is in all likeli- 
hood due to some change in corn caused by para- 
sitic influence, and the idea can not yet be excluded 
that from spoiled corn not only toxic substances 
but parasites as well may be conveyed to the pre- 
disposed human organism, either direct or by means 
of insects or other organisms. 

From its analogy to malaria, piroplasmosis, and 
trypanosomiasis, diseases to a certain extent with 
the same geographical distribution, the thought is 
justified that for the transmission of pellagra some 
similar, intermediate, animal host is necessary; and 
for the intoxication or infection itself some micro- 
scopic animal parasite. Such a parasite must neces- 
sarily be very small, perhaps ultramicroscopic, and, 
although in their researches they found only in the 
erythematous skin of pellagrins bodies resembling 







a v 
33 



a o 



~ a 
5> a 



ETIOLOGY 135 

the smallest Negri bodies, yet the results of arsenical 
treatment encourage new investigations along the 
lines suggested. 

In a very recent note on diplodia disease of corn 
by Smith and Hedges of the Agricultural Depart- 
ment, the suggestion is made that this fungus may 
have some connection with pellagra. The diplodia 
seems to be a fungus which infects the soil and 
enters the grain from the interior of the plant, that 
is, by way of the root system, stem and cob. The 
fungus persists from year to year in infected fields 
and certain soil conditions seem to favor or prevent 
its entering the plant. This mould seems quite exten- 
sively found on corn in the United States. Tira- 
boschi, as noted, has found it only on imported corn 
in Italy. 

Von Deckenbach, as stated by Professor Lombroso 
in his preface to this volume, has recently found 
Oospora verticilloides widely prevalent on corn in 
Bessarabia. From experimental work and investi- 
gation he regards this mould of great etiological 
importance and seems even to think that it will be 
found to bear the same relation to pellagra as does 
the claviceps purpurea to ergotism. 

To sum up, then, it may be said that while the real 
nature and cause of pellagra still remains in doubt, 
there is, nevertheless, a firm and almost universal 
belief that the disease is in some way connected with 
the use of corn as an article of food — a belief so 
universal as to render its rejection well-nigh impos- 
sible except in the face of demonstrative proof to 
the contrary. Ceni's work and ideas, in the present 






136 PELLAGRA 

state of our knowledge, have attracted great atten- 
tion, and in their light many obscure points seem to 
have received illumination, but they still await con- 
firmation. Tizzoni's specific bacillus must yet stand 
the test of time. Sambon's idea rests only on an 
argument by analogy and is at present little more 
than a suggestion, but a highly interesting one. It 
may possibly lead to important developments at the 
hands of investigators. 

Before closing the subject, however, it seems 
proper to introduce here some of the details of Sam- 
bon's more recent investigations.* 

While of course the great majority of the Italian 
medical world hold the view that there is some 
important, if not well understood, etiological rela- 
tion between pellagra and the use of spoiled corn 
as an article of diet, there are nevertheless at least 
some students of the disease who have begun seri- 
ously to question such an etiological relation. And 
this has resulted in a perceptible tendency, more or 
less strong among certain students of pellagra, to 
disregard corn entirely as an etiological factor in 
this disease and to seek some new idea to explain its 
occurrence. This tendency is in the direction of 
some protozoal or animal parasite and has been, in 
all likelihood, produced and stimulated by the ideas 
of Sambon, first expressed in 1905. 

Recently there has been formed a British com- 
mission for the study of pellagra, and Sambon was 
sent to Italy to try to establish his views on the 
etiology of the disease. 

♦This account Is abstracted from Public Health Reports, XXV, 
735, Wash., 1910. 



ETIOLOGY 137 

Samboirs theory has been worked out much more 
in detail than when first presented, in 1905, and has 
attracted much serious attention. His work in Italy, 
largely of an epidemiological nature, has greatly 
strengthened him in his belief in the accuracy of his 
theory and he feels confident of its ultimate proof. 

Succinctly expressed, this theory in its main 
features is as follows, the details having been kindly 
furnished by Doctor Sambon : 

Pellagra is not due to maize, either good or bad, 
because — 

1. It is found in places where maize is neither 
cultivated nor eaten. 

2. It is absent from many places where maize is 
the staple food of the population. 

3. It has in many places either decreased or 
become more prevalent without any change in the 
food of the people. 

4. Its constant and peculiar distribution does not 
agree with the very irregular and ever-changing dis- 
tribution of spoiled maize. 

5. In over a century and a half, since the maize 
theory was first suggested, no one has been able to 
prove it. 

The belief that the disease has everywhere fol- 
lowed the introduction of corn cultivation is 
unfounded. Pellagra was first recognized as a 
specific disease in the beginning of the eighteenth 
century, but this does not prove that it was not 
prevalent long before that time. 

Pellagra is a parasitic disease because: 

1. For years the person affected may present some 



138 PELLAGRA 

seasonal recurrences, which can only be explained 
by a parasitic agent with alternating periods of 
activity and latency. 

2. It shows a constant and characteristic topo- 
graphic distribution. 

3. It shows a definite seasonal incidence. 

4. Its symptoms, course, duration, morbid 
anatomy, as well as its therapy, are similar to those 
of parasitic diseases. 

5. Of two places, almost contiguous, one may be 
affected, the other not. 

Pellagra is an insect-borne disease because : 

1. It is limited, like malaria, sleeping sickness, 
etc., to rural places and more especially to the 
vicinity of certain bodies of water. 

2. It has a definite seasonal incidence — spring and 
autumn. 

3. It affects, to a large extent, a certain class of 
people — the field laborers. 

4. It is not contagious and neither food nor water 
can account for its peculiar epidemiology. 

5. Within its endemic centers it affects all ages 
and frequently whole families. 

6. Outside its endemic centers only adults who 
have visited the infection areas present the disease 
and frequently only one or two members in a family 
are affected. 

Pellagra is conveyed by Simulium reptans be- 
cause : 

1. Simulium is found in the torrents and swift 
running streams of all pellagra districts. 

2. Simulium has the peculiar seasonal distribution 
of pellagra (spring and autumn). 



ETIOLOGY 139 

3. Simulium is found only in rural districts. It is 
unknown in towns and villages. It does not enter 
houses. 

4. Simulium explains most admirably the peculiar 
limitation of the disease to field laborers. 

5. Simulium is the only blood-sucking insect 
which the British field commission has found in its 
visits to numerous pellagrous districts in Italy. 

6. Simulium reptans, like Anopheles maeulipen- 
nis, has a world-wide distribution and explains the 
wide distribution of pellagra. It is found wherever 
pellagra is found. 

7. Simulium causes epizootics in animals in 
America and in Europe. 

8. Professor Mesnil has found a protozoal organ- 
ism in simulium. 

The judicial mental attitude which American 
investigators have so far shown with regard to the 
etiology of pellagra is certainly to be commended in 
the present unsatisfactory status of this question. 
The etiology of pellagra is still an open question. 
The belief that the disease bears some relation to 
spoiled corn has so dominated the etiological field 
and has received the support of so many men of 
wide experience that it can not be now entirely dis- 
regarded ; but certainly it need not be accepted with 
so complete a dogmatism as to prevent investigation 
along other suggestive lines. 

The theory of Sambon is of great interest, and it 
seems that now, when this theory has been elabor- 
ated so much more in detail, it is well worthy of 
serious attention at the hands of American students 
and investigators. 



140 PELLAGRA 

In a presumably semi-official account of Dr. Sam- 
bon's three months' work in Italy* it is stated that 
he carried out his epidemiological survey in the 
provinces of Milan, Bergamo, Brescia, Padua, Rome 
and Perugia. As a result of his investigations Dr. 
Sambon entirely repudiates the maize theory. Ac- 
cording to Dr. Sambon, pellagra is linked to the 
running stream just as malaria is linked to the 
swamp. He claims to have proved that the sand-fly 
{Simulium) explains the epidemiology of pellagra, 
just as the mosquito {Anopheles) explains that of 
malaria. 

As bearing upon the geographical distribution of 
sand flies we have the opinion of so high an author- 
ity as Dr. L. O. Howard, chief of the bureau of 
entomology, U. S. Department of Agriculture, 
Washington : 

"Simulium re f tans does not occur in this country. 
Its only extra-European locality is Greenland, I 
believe. The genus Simulium is represented in this 
country by twenty-seven species. In my opinion Dr. 
Sambon is wrong in his conclusions." 

Furthermore, we may quote from Dr. W. D. 
Hunter, of the same Department, now in charge of 
insect investigations in the Southern States: "All 
the information at hand at present seems to show 
that in this country there is no apparent connection 
between Simulium and pellagra. The centers where 
Simulium is most abundant are along the Mississippi 
Valley from Baton Rouge north to about Cairo and 
in New Hampshire, Maine and New York. From a 

•Jour. Trop. Med. and Hyg., June 15, 1910, p. 180. 



ETIOLOGY 141 

priori considerations, if there is anything in the 
Simulium theory, the centers of pellagrous infection 
in the United States should be in the localities men- 
tioned rather than in the Southeastern States." 

Naturally Sambon's theory may be expected to 
arouse controversy, especially among the Italians. 
Meanwhile, this announcement is interesting: 

"Professor Alessandrini, of the University of 
Eome, who has been for years devoting himself to 
the study of pellagra, has just made a statement that 
he is now absolutely convinced that it is not corn 
which produces this terrible disease, nor is it in 
any way responsible for the malady, but that he has 
discovered the true parasites or germs of pellagra in 
water, which proves to his entire satisfaction that 
water is the vehicle of the disease and not corn, 
which has heretofore been regarded as the cause of 
the dread affliction." 

In this connection it may be wise to quote from 
the Journal of the American Medical Association, 
LV 6, 543, this summary of one of the most recent 
contributions* to the pathogenesis of pellagra : 

"Raubitschek has been applying the biologic, 
anaphylactic, serologic, deviation of complement and 
other tests to determine the actual bases of the 
various theories in regard to the origin of pellagra. 
His extensive experimental work was done at the 
institute for pathology and bacteriology at Czerno- 
witz. The constantly negative results show, he 
thinks, that none of the theories at present in vogue 
is correct. He then reports further research which 



•Wien. Klin. Wochensch, XXIII, 26, 963. 



142 PELLAGRA 

seems to show that pellagra and beriberi are the 
result of the action of some toxine in corn and rice 
which does not display any toxic action unless it is 
sensitized by the chemical rays of the sunlight. 
Laboratory animals fed with corn or rice kept well 
so long as they were not exposed to direct sunlight, 
but under the influence of sunlight developed ema- 
ciation and paralytic phenomena, dying in from 8 
to 21 days. He found that animals taken away 
from the sunlight, soon after the onset of symptoms, 
rapidly recovered, without change of diet. The 
anatomic and bacteriologic findings in the animals 
were constantly negative. He was led to this con- 
ception of the origin of pellagra as the action of an 
alimentary poison plus sunlight by the experiences 
with white animals fed on buckwheat. Kept in the 
dark they remained healthy, while when exposed to 
the sunlight the hair dropped out and the animals 
became emaciated and soon died with symptoms of 
paralysis. This syndrome was not observed with the 
dark-colored animals nor with those kept out of the 
sunshine. The similarity between this 'fagopyrism' 
and pellagra is more striking on account of the facts 
that the pellagra symptoms develop in summer with 
special intensity, that the skin manifestations are 
almost exclusively restricted to the parts exposed to 
the sunlight, that corn has more fat than any other 
grain, and that the active body in buckwheat is sol- 
uble in alcohol. He explains pellagra consequently 
as due to a toxine which develops in the parts of the 
skin exposed to the sunlight from the action of the 
chemical rays on the lipoid, alcohol-soluble element 



PREDISPOSING CAUSES 143 

in corn. The toxine developing in the skin causes the 
superficial lesions and has also injurious systemic 
action. He cites some analyses of wheat, rice and 
corn showing the proportions as follows : 







Dry 








Water. 


Substance. 


Protein. 


Fat. 


Wheat. . 


. . 13.6 


86.4 


12 


1 


Rice . . . 


... 10 


89.5 


11.7 


2.3 


Corn . . 


. . . 10.2 


90 


15.2 


3.8" 



The discussion of etiology can not be concluded 
without some reference to predisposing causes. Pre- 
disposition in pellagra is admittedly a factor of 
much importance in the disease, yet it is often diffi- 
cult to define with exactitude just what constitutes 
the strong predisposing points in individual cases. 

Of course the immense importance of poverty and 
wretchedness, with all that is implied in these terms, 
is recognized by every one. Pellagra is, to a large 
extent, admittedly a disease of the poverty stricken. 
Simply to say, however, that a disease is associated 
usually with poverty is to be lacking somewhat in 
scientific definiteness. A great many different, if not 
diverse, factors are to be found under such condi- 
tions. 

The usually given predisposing causes of pellagra 
are, as follows : 

Seasons, heat, and sun, — The appearance, or recur- 
rence, of the symptoms of the disease in spring is 
almost constant, but the seasons, heat, and sun are 
thought to have only indirect effects in the maturing 
of corn and development of parasitic growths; the 

10-P. 



144 PELLAGRA 

actinic rays of the sun probably often act as an 
exciting cause in the production of the erythema. 

Climate is thought to have no effect beyond the 
indirect influence in growing and maturing corn and 
the development of parasites on the grain. But 
change of climate in beneficial as a means of treat- 
ment. 

Sex seems to exert no influence, though nervous 
symptoms are said to be more dominant in females. 
In our experience in the South females have greatly 
predominated, but this has not been so in other parts 
of the United States. 

Age. — The statements are somewhat discordant, 
but most authors agree that the disease does not 
occur in infants unless they are fed on spoiled corn. 
It seems to occur more frequently between the ages 
of 20 to 40 years. Children are, however, by no 
means exempt. 

Alcoholism, previous sickness, constitution, hy- 
gienic conditions, poverty, venereal excesses, depres- 
sion, pregnancy, and frequent child hearing. — These 
all exert only the indirect influence of lessening 
resistance. It should be added, however, that several 
observers believe that alcohol distilled from spoiled 
corn may contain the pellagrogenous poison. Alco- 
holism and pellagra are not infrequently associated. 

Other associated diseases. — It should be noted that 
such parasitic diseases as anchylostomiasis (uncina- 
riasis) and bilharziosis are frequently present in 
pellagrins. Malaria, too, is common. These are, 
however, regarded only as complications, and not as 
causative agents. They frequently obscure the 
clinical picture of the disease, however. Babes and 
Sion think malaria of great importance, and say that 



PREDISPOSING CAUSES 145 

it often prepares the soil for pellagra. This subject 
has received further discussion elsewhere. 

Nationality and occupation seem to have no effect. 
The disease seems limited to certain countries only 
because of the poor quality of the corn and its con- 
sequent readiness to undergo the change described. 
The poor rural population in Italy are thought to 
suffer most because they live largely, if not exclu- 
sively, on corn and usually of the poorest quality. 
In the South the disease is much more frequent in 
the negro in our experience. 

Heredity. — The disease seems at times hereditary, 
and the children of generations of pellagrins are 
frequently feeble in resistance, and of lowered 
physical vitality, and hence fall easy victims to the 
disease. 

It may be of interest in this connection to add 
that Bass has reported complement-fixation tests, 
with lecithin as antigen, in 16 cases of pellagra seen 
in the United States. His results were : Four of the 
cases, all positive, were ruled out because of syphilis, 
malaria or autopsy blood; eight of the remaining 
twelve gave positive reactions and four negative. 
The four negative cases were of the severe type; 
seven of the positive cases were mild or chronic 
cases ; one was severe. He has called attention to the 
fact that the Wassermann reaction, and its modifi- 
cations with lipoid substance as antigen, have been 
found in protozoan diseases and not in those caused 
by bacteria. The hemolytic unit used was 0.2 c. c. 
sheep corpuscles. The amount of patient's serum 
used per hemolytic unit was 0.1 c. c. The lecithin 



146 PELLAGRA 

solution was 0.1 c. c. of a 0.3 per cent, solution in 
equal parts absolute alcohol and salt solution. 

Fox has also reported 30 cases tested by the No- 
guchi modification of the Wassermann reaction. 
The entire series of cases was tested four times. 
With one exception, no strongly marked positive 
reaction was obtained, and in this positive case a 
complication of syphilis was thought probable. He 
remarks that if such a sensitive test as that of 
Noguchi fails to show many positive reactions, it 
does not seem probable that they will be obtained by 
the regular Wassermann method. For his technic 
and details the original paper should be consulted. 
His conclusions are that cases of pellagra do not 
often give a positive Wassermann reaction. A posi- 
tive reaction, when obtained, is generally weak and 
is easily distinguished from the strong reaction 
found in syphilis and in many cases of leprosy. The 
value of the Wassermann test is not affected by the 
findings in pellagra.] 



CHAPTER V 

Clinical Study of Pellagra.* 

To give any clear and succinct clinical description 
of a disease like pellagra is a task beset with no little 
difficulty. The malady is so protean in its manifes- 
tations and often so varied in its evolution as to 
make a clear and logical description of it by no 
means easy. Almost all writers and clinicians seem 
to have been impressed with this fact and hence 
Lombroso's epigram "There is no disease, only the 
diseased." 

Notwithstanding this, pellagra is a definite mor- 
bid entity and remains true to itself and many 
descriptions of its clinical features have been given 
by which it can be clearly and definitely recognized. 

Most authors, from the time of Frapolli, in an 
attempt to simplify the matter, have in their descrip- 
tions resorted to a more or less artificial division of 
pellagra into periods or stages, somewhat after the 
divisions commonly used in describing syphilis. 
Lombroso, as we shall see later, seemed to regard 
such a division as unscientific, if not inaccurate ; and 
he preferred rather to speak of types, such as the 
cerebral, the gastric, the florid and so on, designating 
each case by its predominating manifestations. By 
far the majority of authors, however, have resorted 
to the division into stages. But the division into 
herpetic or erythematous pellagra, nervous or diges- 
tive, may be rejected because such symptoms may all 
be present simultaneously. 

The elder Strambio, one of the very early writers, 
divided the malady into intermittent, or those having 

•This chapter is by the translators. 



148 PELLAGRA 

symptoms at one season of the year and remaining 
entirely well in the intervals ; the remittent, or those 
having acute manifestations at one season without 
entire recovery in the intervals ; and finally the con- 
tinuous, or grave cases, with constant, severe symp- 
toms. 

Koussel, the great French pellagrologist, in his 
classic work, attempted a more elaborate and more 
logical division. He divided the malady into three 
degrees. 

A. Pellagra of the first degree, or spasmodic pel- 
lagra, corresponding to the intermittent form of 
Strambio. This condition he subdivided into (a) 
commencing pellagra, and (b) confirmed pellagra. 
Here he also included pellagra sine pellagra. 

B. Pellagra of the second degree or paralytic 
pellagra, the remittent form of Strambio. 

C. Pellagrous cachexia, of which he recognized 
two forms, (a) with the eruption, or the continuous 
pellagra of Strambio, and (b) without eruption, 
being in reality a cachexia consecutive upon its 
somatic stigmata. 

Casenave and Schedel, who wrote in the second 
quarter of the last century, pertinently say: "The 
division of pellagra into commencing, confirmed and 
inveterate, is not a practical one, for pellagra may 
be beyond hope from its commencement. The 
expressions period or degree, which convey the idea 
of certain fixed symptoms and appearances, are not 
adapted to the description of a disease so capricious 
as pellagra. The term degree seems to indicate an 
increasing intensity; while the second or third time 










CLINICAL STUDY 149 

of appearance of the disease may be less severe than 
the first. When we employ these terms, therefore, 
we shall use them only as symptoms of a more or less 
advanced step of the disease; for, like every other 
disease, pellagra has a beginning, a progress, and a 
termination." 

Among the more modern authors, Babes and Sion 
speak of (1) a prodromal or pre-erythematous 
stage, (2) an erythematous stage, with gastro- 
intestinal disturbances, and to a lesser extent general 
and peripheral nervous symptoms, (3) a stage dis- 
playing marked nervous and psychic phenomena, 
and (4) a stage of general depression and cachexia. 

Many authors have thought the division of pro- 
dromal, first, second and third stages, being the. 
simplest, is the best; and since any division must 
to a large extent be arbitrary, it would seem just 
as well to use the simplest. But the fact remains- 
that the evolution of pellagra in a given case is 
not so logical as to have one stage succeed another. 
In a general way, it may be affirmed that the 
so-called first stage has reference to the gastro- 
intestinal and skin symptoms; the second stage to 
the cerebro-spinal and psychic phenomena and 
finally the third stage refers to the cachexia which 
follows according to the degree of intoxication or 
the individual's resistance. As a rule, pellagra is a 
chronic affection and the duration of each stage is 
indefinite. Furthermore, the line of demarcation is 
not well defined between the different stages. It is 
well to recognize that from the start pellagra is a 
tropho-neurosis. Neurasthenia is an early and an 



150 PELLAGRA 

almost constant symptom and for the clinician this 
is a fundamental conception of the disease, as will 
again be emphasized in the discussion of the nervous 
and mental stigmata of pellagra. 

Until the etiology of the disease has been finally 
determined, we must be content with the clinical 
summary. 

Again, as in beriberi, cases of pellagra have been 
divided into "dry" and "wet" forms according as the 
cutaneous lesions remain dry or become edematous 
and bullous. The latter condition is of much more 
serious prognostic import. According to Procopiu, 
Soler recognized this division into dry and wet 
forms, the former being met with in dry and 
elevated places and the latter in low and marshy 
territory. Soler says that wet cases have the abdo- 
men distended, and are pale, cachectic and edema- 
tous. The latter form Procopiu regards as asso- 
ciated with malaria. To these conclusions we cannot 
agree. The wet form seems to arise from a more vir- 
ulent form of pellagrous intoxication. Whether the 
wet cases are due to some predisposing or compli- 
cating cause — such as malaria, syphilis, tuberculosis, 
etc., requires further investigation. Likewise the 
possibility of the influence of some secondary 
agencies in these cases must not be lost sight of. 

It should also be remembered that the disease 
picture may not be identical in adjoining countries 
or provinces, to say nothing of different countries 
or remote States. The disease also presents different 
characteristics in the same place at different seasons 
and in different years. The gastro-intestinal type 




IS 



a rj 

"0 g 



CLINICAL STUDY 151 

may be more marked at one time, to be followed at 
another season by more striking cerebral or spinal 
phenomena, and even the type of dermatitis is sub- 
ject to seasonal variation. 

"Pellagra has a course distinguished by pro- 
nounced attacks alternating with periodical amelio- 
rations and exacerbations. The exacerbations occur 
regularly in the spring. During the first attack 
stomachic and intestinal s} T mptoms with nervous 
disorders set in, accompanied mostly by an exan- 
them. In the following attacks the disorders of the 
nervous system become more predominant and may 
cause a plurality of symptoms, attended by a devel- 
opment of general cachexia." (Scheube.) 

Sandwith says the incubation period of pellagra 
is perhaps from nine to twelve months' duration. 
Procopiu thinks this term belongs rather to the 
infectious diseases and should give place to the pro- 
dromal period. 

According to Scheube the prodromal stage lasts 
for a longer or a shorter time. For several winters 
the patient feels languid without cause, and has no 
inclination for bodily or mental work. Most pella- 
grins do not pay any attention to the beginning of 
their malady and only consult the physician when 
the disease has made some progress. But the skin 
does not present the first symptom. 

Pellagrins often complain of fleeting pains in vari- 
ous parts of the body. This is the neurasthenic stage 
as recognized by Gregor, who says that when neuras- 
thenic symptoms have lasted for several years with- 
out obvious cause, the physician should suspect pel- 



152 PELLAGRA 

lagra. Paresthesias and formications are also indi- 
cations of a pellagrous intoxication. 

The patients complain of a sensation of burning in 
the mouth and stomach. Examination of the buccal 
mucosa discloses a general redness, sometimes with 
vesicles or even superficial ulcerations. The salivary 
glands are very active, and the secretion may flow 
involuntarily from the mouth. The saliva is said to 
be acid. Procopiu considers that this ptyalism is not 
due to the buccal lesions but probably depends upon 
the action of the poison upon the glands or upon the 
central nervous system. This stomatitis does not 
occur in all cases, but is frequent. 

For several weeks, sometimes for several months, 
and in rare instances for a year before the 
appearance of the erythema, the patients note a 
progressive weakness, especially of the feet and legs, 
pressure in the stomach and loss of appetite. 

Roussel, according to Babes and Sion, regarded 
loss of appetite, nausea and gastric disturbances as 
complications, while he considered dryness of the 
esophagus, with dsyphagia and pyrosis as the first 
,true pellagrous symptoms. These symptoms, as 
also great hunger, vomiting, cardialgia and diarrhea, 
Eoussel regarded as of nervous origin. In addition 
other authors note vague fleeting pains in the 
extremities and back, roaring in the ears, asthenopia, 
morning tire, often pains in the joints, headache, 
vertigo, and general debility. Babes notes that there 
is often, preceding the erythema, a peculiar redness 
of the lips and tongue, the latter being smooth, slimy 
or in some cases swollen, trembling and fissured. 



CLINICAL STUDY 153 

We have frequently noted a peculiar injection of the 
papillae of the tongue, often pigmented, of an 
intense crimson in the white race and dark or black 
in the negro. It seems to be commoner in the negro 
and gives to the tongue a stippled appearance. 

In European countries the distinctly pronounced 
symptoms of pellagra appear in April and May. 
(Scheube.) In America this is also true, but the 
most numerous and severe cases seem to occur in 
May and June, and in September and October. It 
is also possible that the time incidence may vary in 
different years. Usually the first stage is ushered in 
by gastro-intestinal disturbances. Loss of appetite, 
and disgust for food or bulimia appear. Many 
patients suffer from great thirst, while others have 
an antipathy for drink. Eructations are common 
and the chain of symptoms of so-called nervous 
dyspepsia present themselves. The tongue is coated 
centrally, but its edges are smooth and slimy. 
Papillae are pronounced and often injected. Some- 
times the epithelium of the tongue is shed and we 
have the "bald" tongue of Sandwith, sometimes 
called the "cardinal" tongue. Abdominal distension 
is common and painful. Diarrhea usually sets in, 
the patient having ten, twenty or thirty loose stools 
in twenty- four hours. Dysentery is not infrequent. 
"With the usual paradox of pellagra constipation 
may be present. Many patients complain of hemor- 
rhoids. Vague nervous phenomena now appear. 
Insomnia is characteristic. Headache, giddiness, 
and vertigo are usually complained of, as well as 
ringing in the ears, pains in the neck and back, a 



154 PELLAGRA 

sensation of constriction and feebleness and uncer- 
tainty of movements, especially in the legs. At the 
height of the attack the tendon reflexes are consid- 
erably increased. Psychic phenomena are common; 
depression of spirits, apparent disturbance of mem- 
ory, difficulty in thinking and disinclination for 
bodily or mental exertion. (Scheube.) 

With these symptoms usually the characteristic 
skin manifestation appears. As Sandwith correctly 
says, the eruption, although the least important of 
the various symptoms, has given the disease its name 
and always received an undue amount of attention. 
Following his observations upon pellagra in the 
United States, Howard Fox has recently pertinently 
observed :* "The name erythema, by which the erup- 
tion of pellagra is generally denoted, does not appear 
to me to be entirely appropriate. It would seem 
quite proper to use the term erythema for the first 
stage of the disease, which resembles an ordinary 
sunburn, and which lasts only a few days. But it 
seems somewhat anomalous to speak of the entire 
eruption as an erythema when the erythematous 
stage is so comparatively insignificant, while the 
stage of desquamation is so characteristic and of 
such long duration. An eruption which is called an 
erythema conveys the idea of affections such as 
erythema multiforme or the so-called toxic erythe- 
mata, which are not as a rule accompanied by des- 
quamation. The general term dermatitis would be 
a more appropriate name, in my opinion, than ery- 



♦Personal Observation on the Skin Symptoms of Pellagra, Med. 
Rec., Feb. 5, 1910. 



CLINICAL STUDY 155 

thema for the pellagrous eruption." This dermatitis 
particularly affects the backs of the hands, the lower 
third of the forearms, occasionally also the dorsum 
of the feet; it also appears on the face, neck and 
upper part of the chest, in fact on those places that 
are uncovered and exposed to the sunlight. In the 
case of persons, who whilst laboring go almost 
naked, such as the fellahs in Egypt, the greater part 
of the body is affected. (Scheube.) 

Brault, in Algiers, Nicholas and Jambon, in 
France, and more recently E. B. Saunders in South 
Carolina, have directed attention to a dermatitis 
occupying the whole vulvar region, as well as the 
perineal, the anal fold and the internal surfaces of 
the thighs, which are brought in contact by adduc- 
tion. Here pressure, as was noted by Sandwith, is 
clearly an exciting cause of the inflammatory erup- 
tion. In many of our cases, the surface of the elbows 
and to a less extent of the knees is involved for a 
long while. There is also a tendency for the derma- 
titis to extend from the elbow down the ulna, some- 
times meeting the "gauntlet" coming up from the 
hand. Here again pressure is a causative factor. 

Scheube says: "The skin becomes red and 
swollen, causing the patient to experience a sensation 
of tension, itching or burning. Sometimes little 
blebs and pustules that dry up to scabs develop. 
After the erythema has subsided for a few weeks, a 
desquamation of the epidermis in large patches takes 
place." Rarely this condition does not dry up, but a 
considerable edema develops, followed by bullae, 
pustules and even gangrene. These constitute the 



156 PELLAGRA 

"wet" cases, which form one of the most distressing 
conditions associated with pellagra. Undoubtedly, 
such cases were not infrequently diagnosed derma- 
titis exfoliativa, etc., in the United States prior to 
the recent recognition of pellagra. 

By the end of summer or beginning of winter, the 
condition of patients suffering from first attacks 
ameliorates. But for a long while the skin of the 
affected regions remains either pigmented, rough 
and dry or else appears smooth, shiny and atrophied. 

Again following Scheube's classical description of 
the evolution of pellagra, the illness gradually 
passes into the second stage, which is characterized 
by serious cerebro-spinal symptoms. 

1. Motor Disturbances. Severe pains in the back, 
headache, numbness, cramps and subsulti mark the 
beginning of the second stage. The muscular weak- 
ness of the legs becomes more marked. The patient 
becomes disturbed and distinctly paretic. "The fol- 
lowing motor symptoms of irritation are observed: 
muscular tension and tonic contractions of the upper 
and lower extremities, which may increase to tetanic 
rigidity, sometimes also there is tremor of the arms, 
the head and the tongue; likewise cramps, convul- 
sive jerks and uncontrollable movements of single 
limbs; exceptionally, also there are pronounced 
epileptiform fits with loss of consciousness." (Pro- 
copiu.) "The gait is either simply paralytic or 
paralytic-spastic." 

2. "Disturbances of Sensibility. The sensibility of 
the skin is unequal. The sense of touch remains 
intact, and also the sense of temperature, whilst 



CLINICAL STUDY 157 

much more frequently the sense of pain, particul- 
larly in respect to the legs, is diminished. The mus- 
cular sense is normal. 

"Paresthesia is seen very frequently and in great 
diversity. The sensations of itching and burning 
on the trunk and extremities is the most frequent 
and becomes so intolerable that it drives some 
patients to commit suicide. There is, moreover, the 
sensation of formication, subjective sensations of 
temperature, burning of the eyes, dragging of the 
neck, sensation of suffocation, a feeling of constric- 
tion in the throat and about the chest, a feeling of a 
band round the body, a sensation of weight in the 
region of the groins and uterus or testicles. 

"The tendon reflexes are mostly increased, fre- 
quently to a considerable extent, particularly the 
knee-jerk; very rarely, however, the patellar tendon 
reflexes are either weakened or quite absent. 

3. "Disorders of the Organs of Sense. Occasion- 
ally weakness of vision, hemeralopia, diplopia, 
muscae volitantes and photophobia are observed. 

"After repeated attacks the skin becomes of a 
brown hue and appears smooth, dry and thin : it also 
loses its elasticity, so that it may be lifted up in 
folds, which remain in position. The nails are very 
rarely found normal in pellagra patients, being 
mostly clubbed, ridged, grooved, split, very thin, 
necrotic or overgrown with skin." (Scheube.) 

After repeated attacks or by reason of their 
severity the patient passes to the third or cachectic 
stage. This is really the terminal stage and is 
chiefly characterized by cachexia. The symptoms 



158 PELLAGRA 

already described do not give place to new ones, but, 
on the contrary, they are present and aggravated. 
The cachexia now, however, stands boldly in the 
foreground, with dementia, paralysis, and other 
cerebro-spinal phenomena still prominent in the 
picture. 

There is an increasing marasmus, with marked 
anemia, atrophy of subcutaneous fat and muscula- 
ture, and a lack of resistance against intercurrent 
diseases. In addition there are great muscular 
feebleness, perhaps paralyses, including the bladder, 
and an uncontrollable, painless, serous diarrhea. 
Death follows, with the signs of heart weakness, and 
its consequences, edema, and effusions ; or some inter- 
current disease, such as acute tuberculosis of the 
lungs, which is common at this period, or septicemia 
following decubitus, may close the scene. 

Nearly a century ago, Briere de Boismont con- 
cluded his studies of pellagra with this among other 
corrolaries : "Pellagra is sometimes a primary irri- 
tation of the digestive organs complicated with 
lesions of the nervous and cutaneous systems. Some- 
times a malady of inervation with secondary lesions 
of the digestive functions. In some cases the nervous 
system alone is attacked. The cutaneous stigmata 
which may be wanting are not a criterion of the 
severity of the other symptoms and may disappear 
before the recovery of the patient. These stigmata 
are of secondary importance, and that, too, in all 
cases. 

"The three stages are not as absolutely distinct as 
some claim. The second, which is usually fatal 



CLINICAL STUDY 159 

unless improvement soon begins, may remain sta- 
tionary for several years. The third is incurable. 
Change of location and manner of life exert a happy 
effect upon pellagrins." 

Forms or Pellagra. 

Many forms have been described and various 
divisions made. One or more symptoms may domi- 
nate the picture. 

It will be seen that Lombroso speaks of the dif- 
ferent "forms" of experimental pellagra in dogs as 
anemic, spasmodic and cerebral, and prefers these 
terms rather than that of pellagra in general; and 
furthermore that he regards it as more didactic than 
scientific to make divisions into first and second 
stages (page 102). In man, Lombroso recognizes 
such types as the cerebral, ganglionic, spinal, spastic, 
tabetic, atrophic, gastric, cutaneous, sexual and 
finally the fulminating, florid or tetanic types (page 
183). Lombroso also uses the term period. But sev- 
eral times (pp. 210-214, 227-229) Marie refers to 
stages or periods, and on page 223 to confirmed 
pellagra, thus showing how these terms have become 
engrafted into descriptions of the disease and how 
difficult it is consistently to avoid using them. 

Most of the terms used by Lombroso are self- 
explanatory. Besides these we have also pellagra 
sine pellagra and typhoid pellagra (typhus pella- 
grosus). By pellagra sine pellagra, of course, is 
meant the existence of gastro-intestinal and nervous 
symptoms with the absence of the dermatitis. The 
existence of this type is denied by some writers. 
(Gregor.) 

n-p. 



160 PELLAG&A 

Such a condition, or, in fact, several pellagrous 
conditions without the dermatitis are recognized by- 
different authors. The commonest form is that of 
a persistent diarrhea with the nervous and mental 
phenomena of the disease. E. J. Wood, after former 
skepticism regarding the condition, now seems 
inclined to consider it as a terminal phase of pel- 
lagra.* 

No doubt some cases will be called pellagra sine 
pellagra because the history of the eruption cannot 
be obtained, although it has previously existed and 
disappeared. This is particularly true of insane 
cases, and in these the most careful search should 
be made for the relics of the skin stigmata of pel- 
lagra. Such examinations often clear up the situ- 
ation. 

The term typhoid pellagra (typhus pellagrosus) 
has been employed by nearly all writers upon the 
disease. According to Scheube, it is an acute aggra- 
vation of all the symptoms, more especially the 
mental : "The whole muscular system is in a condi- 
tion either of rigidity or intense tonic contraction. 
The head is buried in the pillows and at times con- 
vulsively moved. On spontaneous movement of the 
limbs a perceptible trembling and indications of 
incoordination are made manifest, and tremors and 
fibrillar contractions are seen in the face from time 
to time. The speech is drawling, tremulous and often 
exhibits a nasal twang. Frequently there are hyper- 
esthesia and heightened reflex excitability, the ten- 
don reflexes in particular being always increased." 

The temperature is frequently high, but the condi- 
tion has been observed by both Italian and German 

♦Trans. Tri-State Med. Assoc, 1909, p. 446. 



CLINICAL STUDY 



161 



writers without elevation of temperature. It is 
hardly necessary to say that the condition has no 
relation to typhoid or enteric fever, although Pro- 
copiu asserts that he has twice seen pellagrins 
develop true enteric fever, and the same observation 
has been twice made by J. J. Watson in this country. 

Furthermore, Procopiu considers typhoid pellagra 
as a complication which may sometimes be due to 
Eberth's bacillus, and then we have an association of 
of the two diseases. He adds that the condition is 
most frequently caused by different kinds of 
microbes, which in the intestines of healthy persons 
have no pathogenic action, but end by overwhelming 
the cachetic pellagrin whose natural resistance is 
greatly reduced. 

Tanzi says: "This (*. e. typhoid pellagra) is a 
very serious incident in the course of pellagra, which 
occurs usually only in extremely inveterate cases 
several years after the onset of the disease. 

"The course of pellagrous typhoid is always 
short: there is no cutaneous rash; the abdominal 
symptoms are accompanied by opisthotonos, epilep- 
tiform attacks; rigidity of the legs, and constant 
delirium, which indicate the special origin. Some- 
times there are added nephritis and uremia, with 
ammoniacal odor of the perspiration, but the urine is 
fairly abundant, and although it contains casts, is 
almost devoid of albumin. Pellagrous typhoid is a 
fatal complication which runs its course in, at most, 
one or two weeks." 

Resume. The above is an outline picture of pel- 
lagra as usually seen by the clinician, but the triad 
of symptoms upon which the diagnosis is usually 



162 PELLAGRA 

based demands, it seems to us, separate and further 
analysis. The descriptions that follow are based 
largely upon the studies of Koussel, Procopiu, Merk 
and Gregor. So far as possible credit is given for 
separate quotations, but it has not been practicable 
in every instance. 

Digestive Symptoms. — A majority of pellagrins 
are dyspeptic, and the dyspepsia often persists when 
the other symptoms have disappeared. Ordinarily 
it is a flatulent and painful dyspepsia. Thus dur- 
ing winter when the patients do not show the char- 
acteristic stigmata of pellagra, dyspepsia and 
gastralgia alone persist. 

In regions where pellagra reigns one may often 
see persons for two or three years before presenting 
the disease picture of pellagra suffer from dypepsia 
characterized by pyrosis, flatulence, eructations and 
painful digestion. This dyspepsia must be due to the 
same cause as pellagra and these persons subject to a 
form of pellagra sine pellagra, that is, pellagra with- 
out the exanthem. Eoussel said with reason : "The 
expression pellagra sine pellagra can only be applied 
to a temporary absence of the cutaneous eruption 
either at the beginning or during the course of the 
malady." But this absence may be of long duration 
when the only manifestation of the pellagrous pois- 
oning consists in digestive troubles. 

Strambio first admitted pellagra sine pellagra. 
Naturally it is difficult always to recognize the 
nature of these dyspepsias and gastralgias, but in 
considering their relationship to the dietary and 
the appearance of the dyspepsia in the spring, one 
may suspect its origin and the removal of the cause 
may of itself lead to the cure. (Procopiu.) 



CLINICAL STUDY 163 

Gastralgia is a later symptom, often developing 
after the others have disappeared. What has been 
said about the dyspepsia applies equally to the gas- 
tralgia. These gastralgias have some resemblance 
to the gastric crises of tabes. They supervene some- 
times in paroxysms and it is not rare for them to 
cause gastric intolerance. They last several days 
and generally have no relation to the taking of food. 

The gastric juice is often less acid in pellagrins. 
The hydrochloric acid is diminished. This fact 
proves that the sensation of burning referred by 
patients to the stomach and which rises towards the 
esophagus is not due to the acidity of the secre- 
tions but to other causes. It is probably a purely 
nervous sensation, or one depending upon lesions of 
the mucosa, analogous to the erythema. This last 
hypothesis appears more probable for the sensation 
of burning of the mouth is always associated with 
hyperemia of the mucosa and with other lesions 
which are found in the stomatitis of pellagra. (Pro- 
copiu.) 

According to Roussel constipation is not infre- 
quent, especially in the earlier stage in pellagra, but 
it may alternate with diarrhea. In the first stage also 
sudden attacks of diarrhea occur, having the char- 
acters of spasmodic phenomena. Strambio distin- 
guished two kinds of diarrhea : the one, a dysentery 
characterized by frequent, colicky and muco-san- 
guinolent stools; the other more common and char- 
acterized by watery discharges, frequency and great 
obstinacy. The dysenteric form is more common in 
the earlier stage, but the serous or aqueous diarrhea 
belongs to the later and progressive stage, and is an 
important factor in producing the cachexia. 



164 PELLAGRA 

The Pellagrous Dermatitis. For the following 
descriptions we are indebted largely to the works of 
Procopiu and Merk. 

The erythema appears early, usually at the begin- 
ning of spring, but there are great variations as to 
the time of its appearance. We have seen that the 
dermatitis is usually preceded by prodromal symp- 
toms, specially of the digestive system. 

Most authors claim that the skin lesions affect 
only the parts of the body exposed to the sun. Merk 
says that it was Raymond who first spoiled the 
vicious logical circle: "The sun produces the pel- 
lagra erythema, because the pellagra erythema is 
only on the parts exposed to the sun." Some writers, 
Calderini and Socor, have described the eruption 
upon unexposed parts. The influence of the sun is 
not to be questioned, but it is secondary. Bouchard 
has shown that it is the chemical or violet rays that 
exercise this action. But the observations of Calde- 
rini and Socor prove that the essential cause of the 
erythema is within the human organism. Procopiu 
thinks that probably the exanthem is due to the 
elimination of the poison by the skin. J. D. Long 
ascribes it to pressure by pellagrous deposits upon 
the spinal nerves at their foramina of exit. The 
assertion of Strambio, Bouchard and others that the 
cutaneous symptoms may be avoided by keeping in 
the shade is not correct. For, granting that the 
exanthem may thus develop more slowly, the skin 
is none the less affected in the shade, but sunlight 
intensifies the eruption, and it is not to be denied 
that the rays of the sun are thus an exciting cause of 
the skin lesions, for the eruption appears upon 



CLINICAL STUDY 165 

unusual sites when the sun's rays penetrate through 
a tear in the clothing. 

General Character. The dermatitis of pellagra 
is characteristic and pathognomonic. When it is 
lacking, the diagnosis is very difficult, especially in 
a region where pellagra is little known. The lesions 
begin as an erythema upon the dorsal surface of the 
hands accompanied by pruritus and burning. Sym- 
metry of the skin stigmata of pellagra is an essential 
feature of the disease. The skin is slightly 
edematous. In some patients several days after- 
wards, blebs appear, which may run together and 
form bullae, containing a serous or sero-sanguinolent 
fluid, which escapes as the bullae burst. When the 
edema disappears the epidermis desquamates and 
falls off in the form of little grayish scales. After 
this desquamation the sensations which accompany 
the lesions improve or disappear. 

In other cases, the epidermis, after having pre- 
sented the characteristic redness, takes on a brownish 
color, separates and falls off in the form of dry 
scales without forming blebs. Sometimes desqua- 
mation of the epidermis is observed without pre- 
liminary redness. In these cases after the shedding 
of the superficial epidermis, the integument remains 
thin, smooth and a deep red. 

Following his careful study of pellagra in the 
United States, James Nevins Hyde has said :* "The 
hue of the exanthem differs according to the color 
scheme of the subject and the length of time during 
which it has existed. At first the color is a dull red, 
which has been likened to the appearance of the skin 
after a common sunburn; yet it is rare that the 

•Am. Jour. Med. Sci., Jan., 1910. 



166 PELLAGRA 

pinkish hue produced by the rays of the sun in the 
skin of a blond subject is precisely imitated. The 
pellagrous erythema at the outset, generally fading 
temporarily under pressure, is more reddish than 
pinkish, displayed at times with discrete macules, 
which speedily fuse and produce, on the backs of the 
hands, for example, a uniformly, smooth, reddened 
and distinctly outlined area, suggesting the appear- 
ance of a glove covering the back of the hand. . . . 
As the evolution of the erythema advances, the color 
deepens, refuses to disappear under pressure, and at 
its height attains a reddish-brown, chocolate or 
plum-colored shade, described as 'livid bluish,' a tint 
at times suggesting that of sepia. The first eruptive 
symptoms may disappear in a fortnight, with epi- 
dermic exfoliation in light flakes, leaving behind a 
pigmentation differing according to the severity of 
the precedent engorgement." 

The dermatitis develops in the same fashion in 
other parts of the body. Upon the face the scales 
are thicker and larger. Pustules have been observed. 
Here there is probably an association with acne, for 
this pustulous erythema, says Procopiu, is met with 
only upon the face. Pustulous inflammation in other 
parts — the perianal and perineal regions and the 
backs of the hands — is probably due to secondary 
infection with the common bacteria of suppuration. 

After several relapses, the exfoliation takes place 
in quite thick lamellae. When the malady reaches 
the second stage, the dermatitis becomes hard, 
rough, cracked, blackish, and brittle. The epidermis 
of the fingers thickens, blackens and becomes indu- 



CLINICAL STUDY 



167 



rated. The articular folds appear deeper. Kaposi 
says that at this period the skin is of a reddish blue 
or a bronzed-brown, with the epidermis thin, satin- 
like and excessively sensitive. Procopiu has found 
it blackish, never reddish blue, and the sensibility has 
appeared to him somewhat diminished. The expla- 
nation of this difference of opinion as to color indi- 
cates that pellagra assumes different color schemes 
in different localities. 

The elasticity of the skin disappears after several 
attacks. Painful fissures develop in the palms of 
the hands. Eoussel erred in asserting that these 
fissures are always foreign to pellagra. In South 
Carolina at times, deep fissures develop upon the 
fingers, especially the index finger. These fissures 
appear after several relapses. The appearances of 
the integument in pellagrins has been compared with 
the skin of the goose, hence it is sometimes called 
"goose skin." 

It is not rare to see small superficial ulcerations 
after the shedding of the epidermis, especially upon 
the extremities. 

When the malady is far advanced, the skin 
becomes hard, dryer, cracked, covered with thicker 
scales, and even with blackish crusts which arise 
from little hemorrhages occurring under the scales. 

Often instead of the erythema, after the falling of 
the scales and crusts, ecchymotic spots appear, which 
Fanzago confounded with the red spots which fol- 
low the desquamation. 



168 PELLAGRA 

In patients at the State Hospital, Columbia, S. C, 
we have seen ecchymotic spots under the epidermis 
of the palms and soles, varying in size from a 
pea to the thumb nail. They sometimes suggest the 
appearance of sub-epidermal freckles. Similar 
stigmata have been observed by Samuel Stern in 
patients at the Philadelphia Hospital for the Insane. 
E. B. Saunders has noted: "The vulvar mucous 
membrane often shows the same 'stippled' appear- 
ance as the tongue. Small hemorrhages, such as are 
observed under the epidermis of the palms and soles 
have been seen under the vaginal and vulvar mucous 
membrane and adjacent skin." Like the injected 
papillae of the tongue, they seem to be hemorrhagic 
and suggest a scorbutic taint. But that they belong 
to the disease-picture of pellagra admits of no doubt. 
The nails are fragile, brittle, and of a grayish color. 
The dermatitis, as does the disease, evolves in a 
periodic manner; it begins in the spring and dis- 
appears at the end of several months to reappear the 
following year at the same time. 

Sometimes the erythema is almost the only symp- 
tom which the patient presents ; other symptoms are 
wanting or only slightly appreciable. But these cases 
are rare; much oftener slight or severe digestive 
troubles exist, their absence being exceptional. 

Localization. The usual sites of the dermatitis 
are, according to Procopiu, the face, neck and dorsal 
surfaces of the hands and feet. Karely it is observed 
in other places. 

Among the common localizations described by 
Merk are : the dorsal surfaces of the hands and feet, 



CLINICAL STUDY 169 

the face, the neck and sternum (the Casal necklace 
and cravat). 

The backs of the hands are the most frequent sites 
of the exanthem. It may be confined to the back of 
the hands or extend up the arm forming the "glove" 
or "gauntlet" of pellagra. The symmetry of these 
lesions is one of the striking characteristics of 
the malady. The cross line is two or three fingers 
above the wrist, or usually confined to the lower 
third of the forearm. The pellagra zone does 
not include all the weather tanned area. The more 
violent the eruption, the higher can the erythema 
zone extend, although this is not a fixed rule. Ray- 
mond thought that the dermatitis spared the last 
two phalanges. This is emphatically not so in South 
Carolina, the fingers being involved to the tips even 
on the palmar side. J. J. Watson, as quoted by Hyde, 
has pointed out a characteristic extension of the pel- 
lagrous eruption on the hands to the flexor surface, 
beginning on the radial border, and reaching toward 
the ulna by an oblique line forming an irregularly 
outlined triangular patch, its base at the radius, its 
apex near the ulnocarpal articulation. 

As to the feet, Merk says the general type fixes its 
proximal limit by a straight line passing directly 
across the ankle in the maleolar region, in fact the 
maleoli are, as a rule, included in the disease zone. 
The heel remains free. Distally the eruption ends 
at the toes or on the backs of the great toes. Usually 
the back of the great toe is most, and of the small 
toe the least affected. In Egypt and the United 
States the dermatitis sometimes extends up the front 
and back of the leg, forming a "boot." 



170 PET J, AGRA 

Upon the face the lesions appear with surprising 
symmetry. Merk recognizes a diffuse and a spotted 
type. In the weakest grades of the spotted type 
only the region of the sides of the nose is affected. 
Then, in order of frequency, the rest of the nose, the 
forehead, the cheeks, the chin, the lips, more rarely 
the eyelids or the ears. The spots are the size of a 
small coin and round, in other cases they produce 
wreath-like figures, or have serpiginous or sinuate 
boundary lines, such as in general belong to the 
erythemata. 

In South Carolina in severe cases, especially in 
negresses, it is not unusual for the dermatitis upon 
the face and nose to assume the "butterfly" appear- 
ance common in lupus erythematosus. The whole 
muco- cutaneous junction is occasionally involved in 
severe cases, the inflammation having a wider area 
at the angles of the mouth. 

The diffuse type on the forehead comes close to the 
hair, but still always leaves a narrow border of 
sound skin between the hair and the erythema. The 
dermatitis is most accentuated upon the glabella, 
forehead, nose and cheeks. The erythema upon the 
face may be so slight as to be overlooked. Casal did 
not note it and Merk gives Frapolli the honor of 
first directing attention to it. In European coun- 
tries it is the women and children whose faces are 
most affected, but in Mexico Yales asserts that the 
faces of men are most frequently involved. This 
facial dermatitis has been called a "mask" by Italian 
authors, and it never appears independently of 
lesions upon the hands and elsewhere. 



CLINICAL STUDY 171 

Casal's "necklace" extends as a tolerably broad 
band or collar entirely around the neck, its upper 
border reaching somewhat below the hair line to 
the Adam's apple in front; the lower border begin- 
ning under the vertebra prominens and extending 
in front to the edge of the manubrium. Sometimes 
the band is only as wide as the finger. Again it can 
be incomplete, leaving the vertebral region or that 
of Adam's apple free, or only the vertebral region 
may be affected. Symmetry of lesions is especially 
noted in incomplete bands. In many cases the neck- 
lace has a front continuation or broad "cravat," 
extending from the manubrium over the sternum to 
the level of the nipples, ending pointedly or square. 
Men, women and childien have the necklace. Merk 
has seen the cravat only in men, but Procopiu pic- 
tures it in a pellagrous boy. We have under obser- 
vation a young negro woman severely affected who 
presents the Casal collar, and a squarish cravat 
extending four inches below the manubrium. This 
eruption is always accompanied by the character- 
istic dermatitis elsewhere. 

According to Merk, it is only within recent years 
— that is, since the skin lesions have not been 
regarded as due entirely to the sun — that atypical 
localizations of the dermatitis have been recognized. 
Merk says Deiaco was the first to describe the der- 
matitis upon the external genitals of females. 
Stephanowics puts in a claim of priority over 
Deiaco. Pellagrous vulvitis and vaginitis have been 
long recognized. Among the atypical lesions men- 
tioned by Merk, are those upon the shoulders, peri- 
anal region, elbows, forearms, knees and scrotum. 



172 PELLAGRA 

Lesions typically located, says Merk, may be found 
in the same case with atypical ones, thus rendering 
the diagnosis easier. But atypical lesions may 
appear entirely alone, though they have not been 
recorded as observed in the erythematous stage. 

In South Carolina, especially among the negro 
pellagrins, dermatitis of the elbow is very common 
and to a somewhat less extent the knees are symmet- 
rically involved. In fact, in doubtful cases involve- 
ment of the elbows is an aid to diagnosis. The relics 
of the dermatitis upon the elbows should always be 
sought for in doubtful cases and in cases of pellagra 
sine pellagra. 

Sometimes the exanthem covers the larger portion 
of the body but rarely it is universal. Such cases 
weaken the solar theory. Again, it affects only the 
backs of the hands. It is entirely absent oftener 
than one would suppose. There are patients who, 
two or three years before developing the character- 
istic dermatitis, suffer from gastralgia and diarrhea, 
especially in the spring. With others the outbreak 
of the exanthem arises from unusual causes, such 
as typhoid fever with Eberth's bacillus. Strambio, 
about 1790, observed that gestation gave occasion 
for the eruption of pellagra, and in this country 
E. B. Saunders has directed attention to the fact 
that latent pellagra frequently develops the charac- 
teristic skin stigmata after a surgical or gynecolog- 
ical operation which may have been performed for 
the removal of nervous or other symptoms. The 
healing of pellagrous skin lesions is usually centri- 
fugal, that is, the line of demarcation may remain 



CLINICAL STUDY 173 

actively inflamed, after the center of the lesion has 
desquamated. This dark zone or fringe frequently 
persists after other signs of pellagra have disap- 
peared and should be carefully looked for in cases 
of pellagra sine pellagra. 

J. J. Watson, of Columbia, S. C, has directed our 
attention to a condition which he has observed 
several times on the hands of patients who have suf- 
fered from a very severe pellagrous dermatitis. In 
addition to the usual glistening and atrophic appear- 
ance of the dorsa of the hands at the site of the erup- 
tion there persists for a long time an apparent vaso- 
motor paresis, the hands assuming a cyanotic hue 
when dependent, but otherwise being red like a 
goose's foot. Rarely there has been noted a dermatitis 
of such severity as to produce a teno-synovitis with 
subsequent restricted movement in the fingers. 

It is by no means uncommon in South Carolina 
for the palms and soles to be almost as severely 
involved with the pellagrous inflammation as are 
the dorsa. While we have not seen them in the ery- 
thematous stage, we have frequently observed them 
subsequently when thickened, indurated, blackened 
and fissured. The subepidermal freckles have already 
been mentioned. The palms and soles exfoliate 
synchronously with the dorsa. The soles appear in 
some cases to be more pigmented. In wet cases the 
activity of the inflammatory process often manifests 
itself first by a hemorrhagic zone at the line of 
juncture of the dorsal epidermis with the thick sole 
of the foot. This inflammation proceeds with much 



174 PELLAGRA 

activity and soon becomes bullous and later purulent. 
When the bullae burst the skin peels off leaving 
a large denuded area of corium. Such cases 
as these often involve the entire surface of both 
feet and hands and show a marked tendency to 
become gangrenous. Other unusual localizations 
are upon the abdomen, the shoulder-blades and 
buttocks, and in wet cases on the inner side of 
the thighs from the groin nearly to the knee, the 
vulva, and over the trochanters. In fact, as com- 
pared with European pellagra, the American type 
of the disease suggests a more active and virulent 
form of intoxication. This view is borne out by the 
frequency of the acute type and the greater mor- 
tality of the disease. In brief the type of pellagra 
now prevalent in the United States is more sugges- 
tive of the Italian disease in the elder Strambio's 
time. 

The Nervous and Mental Symptoms of Pellagra. 

The association of nervous and mental phenomena 
with pellagra is so important as to require separate 
consideration. In Italy it has been variously esti- 
mated that from four to ten per cent, of pellagrins 
become insane. It is now well established that this 
relationship is that of direct cause and effect and not 
an accident or coincidence. 

In the United States up to the present time such 
statistics upon pellagra as we have come largely 
from hospitals for the insane and it is impossible to 
give the ratio of sane to insane pellagrins. 

It has long been recognized that the nervous and 
mental condition of pellagrins undergoes an early 



CLINICAL STUDY 175 

modification. This condition may be ill-defined or 
show itself by a greater psychic excitability in 
which a slight insult or threatened danger com- 
pletely carries them away, thus indicating a lower- 
ing of inhibitory power. Again the patient may 
become hypochondriacal or neurasthenic. 

Gregor believes that the first attack of pellagra is 
more likely to be accompanied by neurasthenia, and 
that this condition commonly precedes the devel- 
opment of the pellagrous psychoses. He recog- 
nizes among the leading neurasthenic subjective 
symptoms: "Headache, pain in the gastric region, 
vertigo, paresthesias, lassitude, mental depression, 
a sense of unrest and anxiety, which may be raised 
to a phobia, as well as ill-defined apprehensions. 
There is also a sense of bodily and mental incapacity, 
and of illness. Their conduct is normal, and the 
intellect may be unimpaired, but they are incapable 
of mental and physical exertion. The process of 
association is distinctly disturbed, the simplest ques- 
tion being answered only after prolonged hesitation. 
With depression of spirits hypochondriac notions 
may develop. In some cases there is slight motor 
unrest, but as a rule these patients labor under motor 
impediment and sink gradually into a condition of 
apathy and resigned inactivity." 

Upon this neurasthenic basis Gregor has seen 
develop distinct psychoses ; such as acute confusional 
insanity including stupor, hallucinosis, acute deli- 
rium, and katatonia, as well as anxiety psychosis, 
and manic-depressive insanity. All these conditions 
he analyzes at length making it appear that in indi- 



12— p. 



176 PELLAGRA 

viduals attacked by pellagra, various psychoses may 
develop. 

Lombroso at one time thought the insantiy of pel- 
lagra was as a rule of an ill-defined, contradictory 
character, like that of old age or anemia, and that 
if it approached a type it was rather that of chronic 
mania and dementia. 

Tanzi is of the opinion that "the first attack of 
insanity occurs after pellagra has existed for some 
years and has already given rise to dermatitis and 
diarrhea and has remitted from time to time. In 
other words, that the pellagrous lunatic is as a rule 
a chronic sufferer from pellagra. But whilst the 
pellagra, although chronic, continues to run an inter- 
mittent course, the mental disturbances associated 
with it have the characters of an amentia," (acute 
confusional insanity). Furthermore, Tanzi regards 
"the insanity of pellagra as something different from 
common melancholia or from ordinary mania. It 
is also something more than simple amentia. We 
may regard it as the combination of two distinct 
clinical pictures, namely, that of amentia in the first 
attacks and that of dementia in the later and pro- 
gressive phases, marked by chronic and incurable 
cachexia. It is an intermittent and progressive 
amentia, which if not cured or if not early fatal, 
terminates in dementia." Or, according to Kegis, it 
may end in chronic mental confusion or in pella- 
grous pseudo-general paralysis. 

Following upon a more or less prolonged attack of 
neurasthenia the patients may thus pass into a state 
of stupor, tending to remissions and marked by deep 



CLINICAL STUDY 177 

depression and a vivid sense of insufficiency. 
(Gregor.) In this manner the several types of pel- 
lagrous psychoses ordinarily develop. 

Among the various nervous diseases that have 
been reported as resulting from pellagra may be 
mentioned neurasthenia, hypochondria, neuralgia, 
chorea, sciatica, polyneuritis, meningitis, myelitis, 
"epilepsy" and "tetanus." Neusser claims to have 
seen amyotrophic lateral sclerosis. Bassoe, of the 
Illinois pellagra commission, according to Hyde, 
after careful neurological examination of nineteen 
cases, divided them into three groups: those with 
probable degeneration of the pyramidal tracts ; those 
with degeneration of the posterior columns and those 
with combined degenerations. These clinical results 
are largely confirmed by the pathological findings. 
(Bowen and Towle.) 

The older writers recognized acute mania, acute 
melancholia, acute delirium, chronic mania, chronic 
melancholia, pseudo-general paralysis and terminal 
dementia. Later writers (Gregor) describe: acute 
confusional insanity (including stupor, hallucinosis, 
acute delirium and katatonia) anxiety psychosis and 
the manic-depressive group, besides several forms of 
dementia, including paresis. 

Antonini, Tanzi and Finzi agree that the type of 
the pellagrous psychosis is amentia, or acute con- 
fusional insanity. Vedrani opposes this view, main- 
taining that the psychosis of pellagra takes usually 
its course without serious disturbance of orientation 
and reason. Warnock and Aubert assume especially 
close relations between pellagra and melancholia. 



178 PELLAGRA 

Baillarger held that the psychoses of pellagra are 
polymorphic, including meningitis, mania, melan- 
cholia, etc., and even general paralysis. Zletarovic 
agrees to this, but says he never saw mania develop 
in a case of pellagra. (Gregor.) 

Many differences of opinion among writers no 
doubt arise from the fact that they have studied 
different expressions of the pellagrous intoxication. 

The effort has been made to classify the mental 
phenomena of pellagra as chronic and acute. Fol- 
lowing Bianchi's description, we may say that in the 
chronic form, the patient shows "general depression, 
melancholia, confusion, slow dementia, paresthesias 
and ataxic gait. Contractures and subsulti are 
absent, although in most cases the reflexes are exag- 
gerated. In the acute form, there is elevation of 
temperature, intense neuro-muscular excitement, 
subsulti, contractures, muscular rigidity, exagger- 
ated reflexes, and confusion with episodes of exalta- 
tion. There are numerous intermediate forms in 
which we observe a great variety of psychic phe- 
nomena, and also alternations of excitement and 
depression. Phases of remission and of apparent 
recovery are observed, especially at certain seasons." 

Procopiu says, "the acute form is more frequent 
when the pellagra is associated with alcoholism, then 
this form presents the characters of delirium 
tremens. The acute form often manifests itself in 
the course of the chronic form, but it can also begin 
in the state of apparent health." It is highly proba- 
ble that the acute form of pellagra described by 
writers is frequently an acute collapse delirium. 



CLINICAL STUDY 179 

Spinal Disturbances. Gregor verifies Toninini's 
observations upon the spinal symptoms of pellagra. 
These are : Increase of the tendon reflexes, increase 
of mechanical muscular excitation, tremor of the 
fingers, rigidities and spasms of the leg muscles, 
spastic gait, diminution of the tactile, thermal and 
fara do-cutaneous sensibility, paresthesias, ataxia of 
the lower, and in rare cases, of the upper extremities, 
and Romberg's symptom. Also muscular spasms: 
tonic spasms being present in patients in the 
terminal stage of pellagra, but clonic spasms are 
also observed and these without the other symptoms 
of typhoid pellagra. Paresis of the lower facial 
muscle was also observed. 

There is also a diversity of opinion as to the group- 
ing of the pellagrous psychoses. Bianchi and Tanzi 
classify them with the toxic group, that is, with the 
insanities from alcohol, morphine, cocaine, etc. 
Bucknill and Tuke place them under the same head- 
ing, while Eegis classifies them with the psycho- 
pathies of the exo-intoxications and Mongeri, under 
the infective psychoses, between post-influenzal 
insanity and Korsakoff's disease. Gregor thinks 
some of his cases might come under the infective- 
exhaustive group, but he admits that the depression 
of pellagra is not dependent upon exhaustion, since 
it occurs also in well-nourished cases and in favor- 
able conditions of life. The term amentia of con- 
tinental writers evidently includes a large propor- 
tion of these cases, for clinically they fall under an 
acute confusional insanity, in many of its phases. 
This classification is further justified by the presence 



180 PELLAGRA 

in many cases of peripheral anesthesia, as empha- 
sized by Stoddart as occurring in this condition. 

As Gregor wisely remarks: The many-sidedness 
of the disease picture explains the view that all 
forms of mental disturbances may occur in pellagra. 
Hallucinations and disturbances of orientation occur 
episodically in the disease. 

Pellagrous Dementia. For the chronic forms, 
dementia is the common termination, but it may be 
complicated by paralysis or tuberculosis. Dementia 
following pellagra shows, according to Gregor, dif- 
ferent forms. One form develops an almost com- 
plete disappearance of mental activity, which justi- 
fies the name "paralytic." But a milder degree of 
dementia characterizes the larger number of cases. 
They are oriented, usually well behaved, but dull 
and show a lack of self-restraint, with a tendency to 
break out into violent passion and impulsive actions. 

A simultaneously existing alcoholism has a modi- 
fying influence upon the disease picture. Further- 
more, in many individuals the pellagrous mental 
disturbance does not appear until old age, when it 
brings about a precocious senile dementia. There is 
also a distinct pellagrous dementia, like paresis, 
marked with somatic changes. 

From our observation and study of the subject in 
America it appears to us that while depression 
(melancholia), stupor and mutism are the ordinary 
psychic expressions of the pellagrous intoxication, 
yet excitement (mania, exaltation) occurs under 
different conditions. First, we may have temporary 
episodes of excitement lasting only a few hours or a 



CLINICAL STUDY 181 

few days; second, an acute, collapse delirium may 
occur at any stage of the malady and usually 
terminates in death in from one to two weeks. It 
may even be an initial delirium. (This is not 
uncommon in the Unied States, and it is sometimes 
called acute pellagra) ; third, the typhoid pellagra 
(typhus pellagrosus) which occurs as a terminal 
phase of chronic pellagra, It is rare in Italy and 
far from frequent in the United States. 

Strictly there appears to be no mental symptom- 
complex characteristic of pellagra, but pellagra may 
act as the exciting cause of several different nervous 
and mental states. These are: neurasthenia, poly- 
neuritis, meningitis, epilepsy, acute confusional 
insanity (including stupor, hallucinosis, collapse 
delirium, and katatonia), anxiety psychosis, the 
manic-depressive group, pellagrous pseudo-general 
paralysis and several other forms of dementia. 

It is not unlikely that the mental symptoms of 
pellagra may differ by seasons, or in different coun- 
tries and in different parts of the same country, just 
as, broadly speaking, do the physical signs and 
symptoms of the disease. 

The tendency of pellagrins to suicide has been 
dwelt upon from the time of Strambio by many 
writers and observers. Our experience in America 
is beginning to teach us how painfully true this 
observation is. 

In conclusion, the protean and often paradoxical 
expressions of this strange malady may again be 
emphasized, and the clinician is warned to be on the 
alert for many unexpected nervous and mental phe- 
nomena when dealing with pellagra. 



J 



CHAPTER VI 

Generalizations — Chief Forms of Pellagra. 
Signs and Symptoms. 

There is a curious saying heard among the poor 
pellagrins of Venetia which shows that a long and 
unhappy experience has made the people familiar 
with the varied manifestations of the malady. This 
is the saying : 

Pellagra can give rise to seven kinds of ills: 

(1) It drives one crazy. 

(2) It drives one into the water. 

(3) It draws one backwards. 

(4) It makes one walk bent. 

(5) It gives one vertigo. 

(6) It gives one ravenous hunger. 
Or (7) It causes rashes on the skin. 

[Sandwith says he has often seen all these varie- 
ties in Cairo, though the second and third are the 
most rare and the fourth is not common. We, too, 
have seen all kinds in this country, though the second 
and third are rare in our experience, and the fifth, 
while fairly common, is not of the severity usually 
described in Italy. Furthermore, Babes and Sion, in 
commenting upon this subject, say : "It is true that a 
popular proverb speaks of different kinds of pel- 
lagra, but they do not stand the test of scientific 
criticism."] 

There are pellagrins in whom there are no dis- 
orders of the skin or of the digestive organs, and 
who suffer most from disturbances of the motor 




Plate XI. South Carolina case. Dermatitis of face, neck, elbows, hands 
and knees. Courtesy of Dr. J. J. Watson. 



GENERALIZATIONS 183 

system (perhaps only a continuous vertigo) and 
from a general debility. 

There are those in whom the phenomena consist 
in grave psychic alterations and changes in motility 
and sensibility, such as various hyperesthesias — 
cerebral, ganglionic or spinal pellagra. 

There are others distinguished by a rapid, extra- 
ordinary emaciation — atrophic pellagra. Then 
there is the gastric form with anorexia, indigestion, 
diarrhea or constipation or voracious appetite; and 
the cutaneous form, with discoloration of the entire 
skin, with erythema, furunculosis or herpes. There is 
one type with unusual sexual excitement. Worst 
of all and fortunately rare there is the form with a 
fulminating course and this is called florid, or 
better, tetanic pellagra. And in experimental ani- 
mals we see analogues of these various types. 

Local Characteristics or Pellagra. 

It is a singular fact that among 600 pellagrins 
observed it was found that many of the symptoms 
of the disease which were common in one locality 
were totally absent in others. 

In the district of Pavia the cases of contractures 
and of mutism are numerous ; but in the district of 
Verona pupillary anomalies prevail. In the latter 
district pellagra (which the people call pelandria 
or salso) is not synonymous with insanity as it is in 
the districts of Pavia, Cremona and Brescia. The 
salty taste in the mouth is met with more frequently 
in the pellagrins of Venetia and of south Tyrol; 
still, in Lombardy this symptom was very fre- 
quently observed in the time of Strambio. In 



184 PET J j AGRA 

Lombardy now one observes rather pain in the 
back, frequent dilatations of the cutaneous capil- 
laries, but rarely scurvy. In the district of Triest 
fewer insane pellagrins are met with, but a larger 
number of cases of albuminuria and of phthisis 
combined with pellagra. One can thus understand 
how the old Italian physicians could confound pel- 
lagra with phthisis. At Mantua that which strikes 
one is the cranial anomalies, which do not exist in 
other districts (possible ethnic influences). 

In the region around Milan the pellagrins have 
frequent epileptiform attacks, whereas they are rare 
in the district of Pavia and are never met with in 
the Tyrol. 

The most frequent complication of pellagra in 
the province of Eeggio is scurvy; in Tuscany 
pterygium is common. 

The observations noted in the various localities 
and circumstances, from the ethnic as well as the 
geographic and climatic points of view, ought to be 
carefully considered and arranged; the different 
kinds of corn, its modes of preparation, exert an 
influence, as has been seen, as well as the climatic, 
and racial factors. It is certain that in a popula- 
tion with a disturbed sympathetic system cases of 
pellagra will be accompanied by vascular dilatation 
and pupillary derangements. A population predis- 
posed by a constant malaria to leucemia and dys- 
entery will be more easily affected by pellagrous 
diarrhea and anemia. 

Cipriani had already found local differences in 
the symptoms of pellagra: In the district of 



FORMS OF PELLAGRA 185 

Mugella the cases were slow and intermittent in 
their course, rarely accompanied by erythema. In 
Romagna and Tuscany the course of the disease was 
more violent and fatal, and the erythema more 
intense. Roussel noted as rare the tendency to 
suicide in the Landes, while at Cannes such cases 
were frequent. In the district of Laragna cases of 
night blindness are numerous; in Spain coarse 
tremor of the head is common. A distinguished 
Italian observer of pellagra, Soler, compares the pel- 
lagra of mountains with that of the plains — the one 
showing the dry form of erythema, the other the 
wet. It does not seem impossible that a purer atmos- 
phere may retard the development of the poisoning. 
Thus, to this cause is attributed several cases of 
semi-immunity observed in mountainous regions 
where individuals of a pellagrous family present a 
very mild type of the disease. Cases of pellagra 
observed on the southern slope of Monte-Baldo were 
not severe; it seems, therefore, that locality plays 
its role. Thus, possibly, Strambio's criticism of 
Soler in this connection would seem unjust. 

Pellagra varies not merely from one region to 
another but also from one individual to another, 
just as one or the other organ offers less resistance; 
and in this lies the reason why there is no other 
disease of which one can say with more of truth that 
"There is no disease, only the diseased." Something 
analogous is found in many intoxications and infec- 
tions, which, although presenting many specific 
symptoms, can present often very diverse lesions. 
Just as the malarial infection, for example, displays 



186 PELLAGRA 

gastric, tetanic and other forms, so similar varia- 
tions are observed in the phenomena of poisoning 
by corn. 

While in the course of pellagra we have an entire 
series of cardinal symptoms of which pigmentation 
of the skin is to be especially noted and the impor- 
tance of which will be shown in the section on path- 
ologic anatomy, still the skin of the pellagrous is 
not merely erythematous, pigmented and desqua- 
mating; it also bears eczematous and herpetic efflor- 
escences, which seem to have some influence on the 
progress of the malady. In many districts, how- 
ever, numerous variations and anomalies are 
observed in the respect just mentioned and in other 
respects. The importance of the genito-urinary 
symptoms is also to be noted. In individuals pois- 
oned by corn observation shows frequent ardor 
urinae, with increased density of the urine, and not 
infrequently dysuria. More interesting still are the 
results of urinary analysis. In certain of these 
pathologic states the urine is increased neither in 
quantity nor in density, but, on the contrary, is 
often diminished; its acidity is lessened and it may 
be neutral or alkaline. In all cases there is a dimin- 
ution of urea, of the phosphates and of the chlorides 
in spite of good nutrition. [In the United States 
the presence of indican is very common.] 

The diminution of muscular force is not a uni- 
versal symptom, but agrees, indeed, with the major- 
ity of the observations on poisoning by corn, as in 
many other kinds of poisoning. 



SYMPTOMS 187 

More specific still, so to speak, are the disorders 
of the sensibility — pruritus, paresthesia; above all, 
sensations of heat; the disorders of the special 
visual sense are observed as in experimental pois- 
oning. Terminal psychic disorders are character- 
ized by stupor without the loss of the intellectual 
functions — they are only suspended. Add the loss 
of sociability, the panphobic tendency to isolate 
one's self, to conceal one's self, the frequency of 
sitophobia, or, on the other hand, hydromania, 
excitement exaggerated by attacks of systematized 
hallucinations. 

Sitophobia explains itself in part by the presence 
of pyrosis and flatulent gastralgia, equally frequent 
in the experiments. Hydromania can be explained 
in several ways, for example, by burning sensations 
of the skin, by hallucinations, by the attraction of 
bright surfaces coincident at times with retinal 
changes and finally by blind impulses, comparable to 
those of epileptic automatism. In the course of these 
attacks of vertigo some of them may fall into the 
water, and their case is then regarded as one of 
suicide by drowning. All this explains, up to a 
certain point, the great number of deaths by drown- 
ing in Italy, in the districts where pellagra is preva- 
lent. It may be admitted that the number of these 
deaths depends, up to a certain point, on the exten- 
sion and the intensity of the pellagra. This exten- 
sion is especially serious for Venetia and Lombardy 
since the cessation of the Austrian occupation, under 
which annual statistics were tabulated. 



188 PELLAGRA 

It is necessary to add to the nervous symptoms 
the frequency of spastic and tetanic phenomena. 

The intermission of the symptoms is explained 
up to a certain point by meteorological influences 
which play an analogous role in alcoholism. The 
pellagrous are particularly sensitive to barometric 
changes. 

Moreover it is important to note the very contra- 
dictory symptoms so often seen in pellagra: We 
note in fact frequently that there are: 

Either Or 

Loss of appetite Voracity 

Somnolence Insomnia 
Sensation of burning Sensation of cold 

Mutism Loquacity 

Constipation Diarrhea 

Hydromania Repugnance to water 
Cataleptiform rigidity Chorea and exaggerated 

and immobility mobility 

Mydriasis Myosis 

Salaciousness Impotence 

Stupor Mental excitement 

Marasmus Florid health 

Apathy Activity. 

Here is reproduced in a double series of experi- 
ments with the poisons of corn a phenomenon 
already definitely established. The explanation is 
that there is a law common to almost all toxic sub- 
stances, which is, in their action upon the animal 
organism they induce a series of opposite effects: a 
primary and a secondary action. It is thus that at 



SYMPTOMS 189 

first aconite stimulates the cardiac plexus, the vessels 
of the heart contract, then the regular beating of the 
organ diminishes (slowness of pulsations, lowering 
of the temperature, etc.) — to these symptoms suc- 
ceed others entirely opposite; the contrast is all the 
more visible when the stimulation of the myocardial 
nerves has been most energetic; the blood pressure 
increases, the heart beats more rapidly and the tem- 
perature rises. With small doses: daturin and 
hyoscin increase the arterial tension; with large 
doses the tension in the vessels diminishes, the intes- 
tines are paralyzed, the sensibility of the skin and 
the temperature diminish. 

According to Brown-Sequard one can produce by 
small, progressive doses of ergot and of belladonna 
contraction of the vessels of the spinal cord and of 
the skin, and diminution of sensibility and the 
reflexes. Toxic doses, on the other hand, produced 
congestion of the meninges, convulsions and hyper- 
esthesia. Poznanski has demonstrated that hydro- 
cyanic acid taken in small doses can produce an 
acceleration of the circulation. 

According to Kegnaud opium taken in small quan- 
tities increases the activity and the circulation of the 
blood in the brain ; in large doses it has the reverse 
effects. The same observation is noted in the stimu- 
lation of the motor functions and of cerebral activity 
by alcohol; these symptoms are followed by a pro- 
found depression of the circulation, of muscular 
force, of intelligence, and by a semi-stupor, etc. 
Such a variety of symptoms is discordant if observed 
from different points of view or in several indi- 






190 PELLAGRA 

viduals. Certain persons can undergo, by reason of 
peculiarities, the first or the second stages; and for 
this reason one ought to view aconite, alcohol, etc., 
sometimes as depressants, sometimes as stimulants, 
in accordance with the course of their action, accord- 
ing to the doses, the personal idiosyncracies and 
many other circumstances as well. But it is just this 
peculiarity of the symptoms of pellagra which 
proves that it is an analogous poisoning. 

Blood and Urine. — The blood in pellagra certainly 
does not contain any trace of a special ferment or of 
any element of infection. Still, it more readily 
undergoes putrefactive changes. It is, however, not 
more deficient in fibrin than normal blood ; except in 
the case of typhoid pellagra. This observation 
should disprove certain old theories about pellagra. 
The examination of the blood of non-cachectic pel- 
lagrins shows only a very small decrease of the red 
blood cells and not infrequently an actual increase. 

[A moderate secondary anemia is quite constant 
in the experience of most observers and this has been 
our experience also. We have practically always 
found an appreciable reduction in hemoglobin.] 
There has been shown in typhoid pellagra in a few 
examinations a notable increase of urea in the blood. 
This fact taken in connection with a very frequent 
sclerotic nephritis and other morbid changes in the 
central nervous system and elsewhere allows the 
deduction that typhoid pellagra is an acute mani- 
festation due to uremic or other complications. 
Hence Nardi, Yerga, Eizzi and Strambio considered, 
with reason, typhoid pellagra as distinct from 
typhoid fever. 



SYMPTOMS 191 

The complication of typhoid pellagra, if we may 
judge from our animal experiments, bears a close 
relation to the renal irritation produced by the 
poisons of corn; and the nephritis is probably of 
toxic origin. It is certain that all the phenomena 
of pellagra seem to indicate a preceding intoxication 
of the spinal cord and sympathetic system. 

For the cardiac plexus this is shown in palpita- 
tions, hypertrophy and especially final atrophy of 
the heart, which, as we shall see, reaches a degree and 
a frequency such as is found in no other known 
malady. On this also depends edema of the articu- 
lations, scurvy and pulmonary emphysema. In the 
acute intoxication by the poison of corn, palpitations 
and syncope are produced as after the lesion of the 
sympathetic nerve ; the systole becomes slower. More 
apparent still is the parallel between lesions of the 
sympathetic and disorders of the intestinal tract; 
these troubles show themselves suddenly in pellagra 
and disappear in the same way, being succeeded by 
entirely opposite symptoms: as anorexia and hun- 
ger, diarrhea and constipation. 

Reflex uterine troubles, without apparent organic 
change on examination are frequently observed. The 
lesion of the sympathetic is much more evident in 
the numerous observed cases of inequality of the 
pupils, a common symptom in grave cases; and also 
in mvosis and vascular dilatation on the same side 
which are the symptoms which C. Bernard, Biffi, 
and others have described as following section of the 
sympathetic. In these cases there exists a correspond- 
ing hemicrania. Is it not probable that in other cases, 

13— P. 



192 PELLAGRA 

as it is certain in this, the cause of the headache 
and perhaps of the vertigo and of the hyperesthesia 
may be entirely ganglionic and depend upon a 
hyperemia produced by ganglionic paralysis? 

It is to be noted in this connnection that the 
various painful reflexes and the cerebro- cardiac 
neurosis, palpitations, trismus, etc., can be made to 
disappear by electric stimulation of the cervical 
ganglion. Going a step further could we not with 
time relegate to this cause even the cutaneous lesions 
of pellagra, whose dependence upon the nervous 
system is indicated by such associated symptoms as 
pruritus, sensations of heat and hyperesthesia? The 
frequent ptyalism of the pellagrous is also physi- 
ologically connected with the disorders of the sym- 
pathetic. The experimental spinal symptoms, the 
numerous cases of spastic paralysis, tetanus, the 
increase of the reflexes and of the muscular tonus^ 
the tremor, the motor incoordination of the superior 
extremities denote, as Belmondo says, the degenera- 
tions of the crossed pyramidal tracts and of the gray 
matter of the spinal cord, as pathological anatomy 
makes it appear; likewise hyperesthesia and deli- 
rium denote a cerebro-spinal meningitis. 

Weight. — The loss of body weight is not always 
(as has been seen) a constant symptom of pellagra 
(Strambio). It is found, however, in 84% of the 
cases of women and 74% of the men. Calderini finds 
out of 1,005 cases 514 notably under weight. In 
general the diminution of the weight proceeds par- 
allel with the progressive repugnance to food. It is 
a clinical symptom of prime importance, as it is also 



SYMPTOMS 193 

in experimental animals. The average weight of 
108 pellagrous women was 44.6 kilograms, that of 
100 pellagrous men was 62.5 kilogrammes. How- 
ever, there were found among the women 6 who 
went beyond 58 kgr. and one of 68 kgr. ; among the 
men 12 weighed more than 50 kgr., 6 more than 54 
kgr. and 8 more than 60 kgr. One man, who died 
of acute pellagra, weighed 86 kgr. and had a strong 
muscularity. Another man, very old, with a form 
showing a tendency to vertigo, weighed 72 kgr. 

Calderini finds in 1,005 cases of pellagra 491 with 
full and florid faces ; according to Xardi and Nobili 
the cases showing an evident diminution of weight 
seem more curable than those which show an 
increase. The half, at least, of the most severe cases 
of typhoid pellagra are observed in individuals well 
nourished and of strong constitution. This is explain- 
able when it is a question of young persons, or, 
indeed, of the well-to-do classes. Cases of this kind 
have been observed by Odoardi, Alpago-Novello, and 
it is known, indeed, that persons in good circum- 
stances are not only heavier, but taller than poor 
people. 

The Skix: The skin presents, besides the cus- 
tomary general phenomena of erythema and telan- 
giectatic spots, not infrequently other peculiar 
appearances. Landouzy and Lombroso have noted 
not rarely a pigmentation of a chocolate or bronze 
color, and a thickening of the epidermis in sites 
of a previous erythema. Certain pellagrins affirm 
that at the beginning of the disease the skin of 
the entire body has assumed a darker hue. In 
many of the sick are found ephelides and chloas- 



194 PELLAGRA 

mata scattered principally over the brow and chest. 
Sometimes each spring the chloasmata were preceded 
by red spots on the face which resembled the erup- 
tion of rubeola. In the case of an old female pella- 
grin, who suffered from brachial neuralgia, the 
entire skin was of a bronze-like color and the arms 
showed an eczema of a scaly nature which later 
became ulcerous. 

Premature and extensive wrinkling of the skin 
has been observed, and increased activity of the 
sweat glands even in winter. The phenomenon of 
a species of antagonism between the appearance of 
cutaneous symptoms and the nervous and muscular 
disturbances of pellagra, once observed in animals, 
was also seen three times in about one thousand 
cases. One case in which there had been for two 
years vertigo, burning sensation on the back, 
diarrhea and melancholia, enjoyed entire relief 
from these symptoms upon the appearance of a per- 
sistent acne rosacea; in another case an old man of 
eighty-two years showed improvement in his pella- 
grous manifestations after the appearance of a scaly 
herpes upon his face; in a third case a woman of 
Novaro, thirty-four years old, with pellagrous 
delirium and a marked cachexia, having developed 
smallpox regained her calm and was even relieved 
of a pellagrous diarrhea. 

Others have likewise observed that the desquama- 
tive lesions of the skin bear no relation to the gravity 
of the disease. Strambio says: "And, indeed,, 
although often in the beginning their unsightly 
scaly eruption is sufficient to excite the pity of all, 



SYMPTOMS 195 

still, after a few days all the skin manifestations will 
disappear. Therefore, the intensity of the disease is 
not to be measured by the scaly eruptions." [It has 
been our experience that extensive, moist dermatitis 
is almost always associated with grave constitu- 
tional disturbances. Similar reports are made by 
other American observers.] 

A rare symptom in the neighborhood of Pavia — 
while in Venetia and Tuscany it is frequent — is the 
dilatation of the venules of the face, especially of 
the nose, which gives the pellagrin the appearance 
of a toper. Very often a brownish color of the skin 
is observed, particularly of the face, especially in 
the country districts of the southern Tyrol. 

In only three cases was there found edema of 
the eyelids and traces of edema of the feet. In four 
cases thickening of the finger nails was noted, twice 
on the right side only. 

Head and Organs of Special Sense : Anomalies 
of the cranium are rare among pellagrins even 
when insane. They are more frequently found in 
other insanities — about eight per cent, in the former 
and over twent3 r -one per cent, in the latter. The only 
exception to this rule is found in hereditary pella- 
grins, a great part of whom show a general increase 
in cranial diameters with a relative predominance 
of the transverse diameter, similar to what is seen in 
cretins. In these hereditary pellagrins are also 
found numerous deformities of the skeleton of the 
face (eurygnathism and prognathism) which 
remind one of the negroid and mongolian types of 
degeneracy. Diverse peripheral anomalies are like- 
wise very numerous among hereditary pellagrins. 



196 PELLAGRA 

Eye Symptoms: Remarkable peculiarities are 
found in the eyes of the pellagrous ; a falling of the 
supercilliary fold is very frequent in severe cases — 
even unilateral ptosis is not rare. Inequalities of 
the pupils are very important and dilatation in 
the right eye is very frequent. In many cases 
is found also a marked unilateral injection of 
the conjunctiva. These are observations which 
remind one of general paresis, and show, along with 
other manifestations, how frequently the lesions of 
the nervous system may be unilateral, especially 
lesions of the sympathetic system. 

Very often also (74 cases) mydriasis of the two 
sides is found. Myosis is more rare and when found 
is more usual in the aged. Cases of blepharitis are 
not rare as was shown by the Piedmont commission. 
Often also diplopia, photophobia and synchysis are 
found. Many pellagrins remain for years with their 
eyes closed for fear of the light. Early cataracts 
are found among the pellagrous; and pterygium is 
not infrequent. Dr. Ottolenghi, with Professor 
Manfredi and Dr. Flarer have made ophthalmic 
studies on pellagrins. Their results are given in the 
following table: 

Number examined 36 

Depth of eye normal 12 

Changes in the retina 15 

Atrophy of arteries 12 

Anomalies in fundus of left eye 1 

Anomalies in fundus of right eye 6 

Atrophy of optic nerve 3 

Increase of pigment 3 

Dilatation of the veins 1 



SYMPTOMS 197 

Fifteen of these cases showed retinal changes by a 
yellow or gray reflex in one or both eyes — a sign of 
precocious senility ; it is of interest to note that there 
were three cases of white atrophy of the papillae, 
among which was one case of retino-choroiditis in an 
advanced stage. Ottolenghi found also in three pella- 
grins one light case of papillitis, more pronounced 
in the left eye ; in the second case pronounced gray 
atrophy and diffuse retino-choroiditis of the two 
sides ; the third was normal. It is of interest to note 
the observation that in several individuals the ocular 
fundus differed on the two sides. This, however, 
cannot be given as a reason for the numerous pupil- 
lary inequalities since these are noted in individuals 
who show a normal fundus. However, the unilateral 
anomalies of the fundus as well as those of the pupils 
predominate in the right eye and consist in lesions 
of the arterial vessels with papillary and retinal 
changes. Kampoldi observed pellagrous ocular 
troubles principally in the autumn or the spring,, 
and found that they consisted of organic lesions: 
rather than functional disorders. The retina and 
optic nerve show more than any other part of the 
eye the pellagrous cachexia, next come the cornea 
and lens; finally the choroid and vitreous body. 
Hemeralopia and pigmentary retinitis are not rare. 
Torpid ulcers of the cornea are found with essential 
hypotonus of the bulb and scintillating synchysis 
of the vitreous. 

[We are indebted to Dr. E. M. Whaley, of Colum- 
bia, S. C.j for the following report on 



198 pellagra 

"Eye Findings in Thirty-five Pellagrins. 

"The number of cases examined was thirty-five, 
their ages varying from eight to seventy-six years, 
only two of whom showed normal eyes. 

"The appearance of the patients was that they did 
not carry their upper lids as high as they should, 
thereby giving the appearance of general lassitude. 
In considering this report it should be remembered 
that more than half of the patients we are dealing 
with are afflicted with insanity, which would natur- 
ally make us expect to find the nervous element much 
in prominence and the disease well advanced, except 
a few in whom it has developed since their stay in 
the hospital and among the younger subjects. 

"All pellagrins are unresponsive and no field 
examination could be made; with few exceptions 
the examination had to be made while the patient 
was in bed. The dilated pupil so much spoken of 
by the Italian observers was not so prevalent with 
us, it having occurred bilaterally in three cases only ; 
unilaterally, in two cases, and one of the bilateral 
cases was myopic. Two cases resisted the action of 
homatropine for two hours, four resisted it less 
strenuously, while the others reacted in the usual 
twenty minutes. Hypersensitiveness to light with 
contracted pupils was the rule. 

"Shallow anterior chambers were found in thirty- 
three per cent, of the cases. Strabismus could not 
be detected when there was not other evident cause. 
Where the gastro- intestinal symptoms are very 
pronounced and the inflammation extends to the 
mouth and post-nasal space, we find an obstruction 
of the lachrymal duct due to continuity of surface. 










Plat 



XII. Egyptian case, compare with Plate XI. 
Dr. F. M. Sandwith. 



Courtesy of 



SYMPTOMS 199 

This was noted in five cases all of which had the 
mucous membranes very much affected by disease. 
Photophobia of slight degree without the inflam- 
matory changes which usually accompany this condi- 
tion was present in six cases. 

"The findings as tabulated are as follows : 

"Lids: Paretic, one; lachrymation, two; dachry- 
ostitis, two; conjunctivitis, two; muddy conjunc- 
tivae, two; jaundiced conjunctivae, three; obstruc- 
tion of lachrymal duct, five. 

"Corneal Abnormalities: Ulcer, four; superficial 
inflammation, two; increased sensibility, two; sub- 
normal sensibility, seven. 

"Muscles: Paresis (right rectus), one; nystagmus, 
one. 

"Anterior Chamber: Shallow, twelve; deep, one. 

"Iris: Iritis serous, one; sluggish reaction to 
light, six; hypersensitive, four; photophobia, six; 
reaction to homatropine, slow, four; prompt, one; 
spastic reaction to light, two. 

"Pupils: Unilaterally dilated, two; bilaterally 
contracted, three; bilaterally dilated, three; Argyle 
Robertson, one. 

"Tension: Plus bilateral, one; plus unilateral 
(O.S.),two. 

"Fundus: Retinitis, two; detached retina, one; 
optic atrophy, three ; optic neuritis, three. 

"Lens: Cataract bilateral, three; unilateral, two; 
cloudy lens, one. 

"A rteriosclerosis, fifteen. 

"After examining somewhat over half of these 
cases, I found that there was most common a dilata- 
tion of the retinal veins and a somewhat yellowish 



200 PELLAGRA 

reflex from the retina which I do not recall having 
seen elsewhere. This appearance is hard to describe, 
appearing as a thickening of the retina itself. 

"The arteriosclerosis which appears in so many 
of the cases is of every stage and occurs in the young 
as well as in the older cases.] 

Thoracic and Abdominal Organs: Strambio 
noted the slow pulse rate in pellagrins, a decrease 
often to 40 and even to 34 per minute. Lom- 
broso, however, has more often noticed a rapid 
pulse, 100 to 105, frequently filiform in character 
and difficult to feel. In three-fourths of the cases, 
principally in the young, a sensible diminution is 
found in cardiac force. The apex beat is often not 
visible, sometimes barely perceptible on palpation, 
and is frequently displaced downward and outward 
between the sixth and seventh ribs, to the breadth 
of two to four fingers and a half below the nipple. 
Frequently the sounds of the heart are difficult to 
hear. In aged persons, however, the left ventricle 
is often hypertrophied, there is mitral insufficiency 
with dilatation, and the first sound at the apex is 
replaced by a blowing murmur. 

Gastric Symptoms: Pyrosis and eructations are 
very frequent. Constipation is observed usually 
in those upon whom the disease has not produced 
profound effects. Sitophobia is a frequent condition 
in insane pellagrins, but even the non-insane cases 
often show profound repugnance for food, especially 
meat, and, strange to say, polenta ; on the other hand, 
many suffer from a continual bulimia and will 
consume a quantity of nourishment double or triple 
that of a well man. A pellagrous woman exhibiting 



SYMPTOMS 



201 



this voracious appetite, a little before delirium set 
in, left her house in order to keep from devouring 
her children. 

With regard to liquids also the pellagrous often 
show marked peculiarities. Many complain of an 
unquenchable thirst and drink enormous quantities 
of water. Others have a great repugnance for 
liquids. One complained that after having drunk 
she had the sensation of a stone in her intestines. 
Many find a salty taste in water; others have a 
repugnance for cold water and must drink the 
water hot or lukewarm. 

Lombroso, Filippi and Roncoroni examined the 
gastric juice of two pellagrins. The stomach was 
found almost completely empty, the first time four 
hours after food and the second time one and a half 
to two hours thereafter. The test meal consisted of 
a porringer of soup, 85 grams of meat, 200 grams of 
bread and 100 grams of wine. Four tests were made 
on each individual. Hydrochloric acid was found 
to be generally diminished and the presence of lactic 
acid frequent. The following table gives full results : 



Analyses. 



Case 1. 



Case 2. 



Reaction of gastric 
juice. 

Hydrochloric acid 
(Gunsberg reac- 
tion). 

Lactic acid (Uffel- 
mann reaction). 

Percentage of acid- 
ity. 

Peptone (Biuret re- 
action). 

Digestion of starches 



Once neutral ; three 
times slightly acid. 
Always negative. 



Present three times 

out of four. 
Average, 60%. 

Present. 

Twice complete ; 
once arrested in 
the second stage. 



Acid. 

Always negative. 

Always appreciable 

Average, 50%. 

Present. 

Three times com- 
plete ; once ar- 
rested in the first 
stage. 



202 PELLAGRA 

[Nesbit at the National Conference on Pellagra, 
1909, reported the results of the analyses of the 
stomach contents of 10 cases of pellagra. Four 
showed a marked diminution in the acid factors of 
the gastric juice in the late stage of the disease. 
Five showed an excess of mucus during the pella- 
grous periods. Six showed normal motility, while 
in three the motility test was not made. Four 
showed the presence of bile during severe vomiting 
periods. He remarks that while this series of cases 
is too small for definite conclusions, the indica- 
tions are that in pellagra, as in all adynamic and 
asthenic diseases, the hydrochloric acid and ferments 
of the gastric juice are progressively diminished.] 

The Genito-Urinary functions present phenom- 
ena worthy of note. Even though the urine be clear 
many of the pellagrous complain of a burning pain 
on urination; others feel a sensation of heaviness 
and of cold in the groin or around the uterus ; others 
complain of a retraction of the penis, or again a 
sensation of painful heaviness in the testicles. In 
many of the hereditary pellagrins the hair around 
the genitals is wanting and the testicles are atro- 
phied. In hereditary pellagrous women are noticed 
atrophy of the breasts, irregularity or absence of 
the catamenia, which is sometimes followed by a 
painful metrorrhagia. 

Calderini notes dysuria in 74 per cent, of the men, 
and in 57 per cent, of the women, amenorrhea in 
50 per cent, leucorrhea in 50 per cent, and abortion 
in 17 per cent. Many cases suffer from subjective 
sensations of uterine inflammations or displacements 



SYMPTOMS 203 

without objective signs. A robust country woman 
in the hospital at Verona, thirty-one years old, the 
mother of five children, complained of violent pain 
on urination and a sensation of weight in the uterus, 
"as if it were made of lead," with burning at the 
cervix uteri. She would not tolerate a speculum 
for examination, but was treated a long while for 
metritis. Finally she began to complain of epigas- 
tric swelling, burning on the back, alternate sensa- 
tions of hot and cold, and had diplopia; later she 
developed a melancholic mutism without adequate 
cause. It was then thought that perhaps the uterine 
symptoms might be of a pellagrous nature. A care- 
ful examination with the speculum showed no trace 
of a metritis. It was a case of unrecognized pellagra. 

[At the National Conference on Pellagra, 1909, 
Eleanora B. Saunders presented a very thoughtful 
paper on the gynecologic, obstetric and surgical 
aspects of pellagra which is well worthy of serious 
attention in this connection. Surgeons, especially 
gynecologists, should bear pellagra in mind if they 
would avoid occasionally useless, and even harmful 
procedures. 

Dr. Saunders's paper is summarized as follows : 

"To sum up my observations and reading upon the aspects 
of pellagra embraced in this paper, of the 24 cases reported. 
4 patients are still under treatment, 10 recovered, and 10 
died. In America and Roumania the female sex is more 
liable to pellagra, the periods of greatest incidence being the 
twentieth to fortieth year. Obstetric. — Pregnant women 
suffering from pellagra are liable to abortion (17 per cent), 
to give birth to still-born infants, and at delivery to post- 
partum hemorrhage. Gestation and lactation, especially 



204 PELLAGRA 

when frequent, predispose to pellagra. Parturition is often 
an exciting cause for the outbreak of the dermatitis. 
Gynecologic : amenorrhea and leucorrhea occur in 50% of the 
cases, and dysuria in 57%. Unmarried female pellagrins are 
more subject to amenorrhea. Multiparous pellagrins are 
liable to menorrhagia, and present symptoms suggesting can- 
cer. Their subjective symptoms may point to diseases of the 
pelvic organs and require careful examination for their 
exclusion. Not uncommon are vulvitis, vulvovaginitis, cervi- 
cal erosions, endocervicitis and endometritis, ovarian neu- 
ralgia and inflammation, maceration and denudation of 
adjacent skin on the thighs and in perineal and anal regions, 
especially in 'moist' cases. A surgical operation may bring 
out latent pellagra. Diseases of the kidney are simulated 
and may be primary or secondary. Stomach symptoms are 
often so severe as to require attention and rigid diagnostic 
methods. Care should be exercised to prevent needless 
surgical or other treatment. Other subjective symptoms 
may annoy the patient to such an extent as to demand treat- 
ment. Pellagrins often complain of symptoms suggestive of 
hemorrhoids when it is really proctitis, a part of the general 
inflammation of the intestinal mucosa and adjoining epi- 
dermis. In essence, pellagra may be a trophoneurosis, but 
that in women the pelvic organs are especially subject to the 
invasion of the unknown poison, is a fact demanding wider 
recognition as well as further study. 

"In asylum life we see a few failures among many bril- 
liant surgical successes, but the above surely points to the 
fact that in the initial stages, especially when the symptoms 
are not very well marked and when there is much pointing 
to pellagra as well as to other diseases, a very careful differ- 
ential diagnosis should be made and care given to other than 
the pelvic symptoms of these cases. If possible, relieve the 
primary disorder, pellagra, before resorting to radical oper- 
ations, which, at best, cannot cure pellagra, and will 
probably only increase the already lethal tendency. Not 
much will be lost in waiting for a time, at the expiration of 
which the symptoms may have been relieved, or the pellagra 



SYMPTOMS 



205 



erythema now so necessary for diagnosis have appeared in 
full efflorescence. Patients with pellagra, on account of 
their debilitated condition, are prone to other diseases, and 
are subject to 'incidentals' which require surgical inter- 
vention. These demand and should have prompt attention, 
but after granting all this, I am forced to believe that the 
majority of such patients should be treated not as having 
a primary organic pelvic disease, but as suffering from 
functional or symptomatic disorders, and, furthermore, that 
the gynecologic, obstetric and surgical aspects of pellagra 
are factors which not only the general practitioner must 
consider, but with which specialists of several kinds who 
live in the pellagra zone must hereafter reckon for the real 
welfare of their patients."] 

The Blood : In a study of eighteen cases of pel- 
lagra it was made apparent that there was no 
decrease in the number of red cells or in the quan- 
tity of fibrin as had formerly been the opinion. 



TABLE OF THE QUANTITY OF FIBRIN AND NUMBER OF RED 
CELLS IN EIGHTEEN PELLAGRINS. 



u 

i 

JO 

s 

3 


i 

< 


Sex. 

Quantity of 
Dried Fibrin 
by Weight. 


00 . 

a) as 

- — 

O 3 


Number of 
Red Cells. 


Remarks. 


1 

2 
3 

4 

5 

8 

7 

8 

8 

10 

11 

12 

13 

14 

18 
16 

IT 

1% 


40 
21 
50 
40 
40 
18 
56 
18 
25 
41 
37 
40 
38 
38 

4f, 
45 

43 
29 


Male. 

Male. 

Male. 

Male. 

Male. 

Male. 

Male. 

Male. 

Female. 

Female. 

Female. 

Female. 

Female. 

Female. 

Female. 
Female. 

Female. 
Female. 


0.157% 
0.169% 
0.400% 
0.260% 
0.008% 
. 201 % 
0.150% 
0.173% 

'6! 180% 
0.350% 

'6. '666% 

0.282% 

0.013% 
0.173% 

0.024% 
0.157% 


4 

3 
3 

5 

6 

8 

ii 

9 
4 

8 
4 

3 
3 


5,125.000 

'5,250,666 
5,250,000 

'5,666,660 

'4,875,66b 
4,625,000 

' 4,250,66b 

4,500,000 
5,125,000 
4,625,000 

5,125,000 
5,250,000 

5,250,000 
5,250,000 


Robust. 
Thin. 

Very robust. 
Emaciated. 
Emaciated. 
Fat. 

Very robust. 
Robust. 
Very robust. 
Typhoid pellagra. 
Emaciated. 
Convalescent. 
Typhoid pellagra. 
Convalescent from ty- 
phoid pellagra. 
Typhoid pellagra. 
Convalescent from ty- 
phoid pellagra. 
Robust. 
Robust. 



206 PELLAGRA 

From an analysis of this table it is seen that ordin- 
arily not only is the fibrin not diminished, but some- 
times it is even increased (2 cases in 18) ; in four 
cases in which it was diminished, two were typhoid 
pellagra, and in these after the disappearence of the 
typhoid symptoms the proportion of fibrin again 
became normal. The diminution of fibrin, there- 
fore, cannot be regarded as a sign of pellagra. The 
number of red cells appears almost constantly to 
follow the fibrin, no sensible diminution was noticed 
except once in a woman convalescent from pellagra 
who was subject to malaria and lived in a fever 
district (Certosa). The diminution of the number 
of red cells is not sufficient to justify one in talking 
of anemia; it was noted, however, in three cases of 
typhoid pellagra. These results are confirmed to 
a certain degree by studies made with the Bizzozero 
instrument by Sepilli at the ay slum for the insane 
at Reggio. He found in 55 pellagrins 

13 (23 per cent.) showing 80-95 per cent, hemoglobin. 

15 (27 per cent.) showing 60-85 per cent, hemoglobin. 

18 (32 per cent.) showing 50-65 per cent, hemoglobin. 

4 ( 7 per cent.) showing 30-50 per cent, hemoglobin. 

[Five of these cases are omitted.] From these 
results it is obvious that a fair number of pellagrins 
do not suffer any reduction in hemoglobin ; and con- 
sequently anemia, while a frequent, is not a con- 
stant characteristic of pellagra. This accords with 
the experimental work done on dogs. 

These observations serve to show the uselessness of 
treatment with iron, a remedy which has been much 
employed; the ferruginous district of Ricoaro con- 



BLOOD 207 

tains a large number of pellagrins. Several authors, 
as Liber ali and Robolotti, have even recommended 
the letting of blood. The drawing of 100 to 150 c. c. 
of blood practiced in the course of hematological 
researches on pellagrins, even in typhoid pellagra, 
appeared harmless, though sometimes beneficial. 

The examination of the blood of an hereditary 
pellagrin of Regis, made by Professor Sabrazes, 
gave this result: 

Hemoglobin 75 per cent 

Coagulation time (Sabrazes method) . .9 minutes, 12 seconds 

Red cells 2,449,000 

White cells 6.200 

On bibulous paper the blood made a clear spot 
without a watery border; no red cells with baso- 
philic degeneration; inequalities in the size of 
the red cells with numerous microcytes; some 
poikilocytes ; a few polychromatic red cells; no 
nucleated reds. 

Polynuclears 63.3 per cent. 

Lymphocytes 32.6 per cent. 

Mononuclears 3.4 per cent. 

Eosinophiles 7 per cent. 

Lumbar puncture was also done. The examination 
of the cerebro-spinal fluid was negative. 

[The next table shows results obtained by us in 
blood counts made at Columbia, South Carolina: 



14— p. 



208 



PELLAGRA 



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BLOOD 209 

The technique of making these counts was as fol- 
lows: The Thoma-Zeiss counting chamber, with 
Turck's ruling, was used; in counting red cells the 
four corner unit squares (25 small squares each) 
were counted in two preparations, and if the results 
were discordant a third was counted; in counting 
white cells the whole ruled space was counted in two 
preparations; and again, if results were discordant, 
a third preparation was counted. The hemaglobin 
estimation was made with a new Dare instrument, 
which gave very uniform readings in normal indi- 
viduals. 

The cases were mostly of an advanced type with 
many secondary nervous changes, and nearly all 
alienated. Most of them were negro women. The 
greatest number of the counts were made at the same 
time of day (morning) and under the same circum- 
stances as far as possible. Many of the patients had 
been taking arsenic in some form with full doses, 
either at the time of the examination or not a very 
long while previously. 

A brief analysis of this table shows a frequent 
reduction in red cells and in hemoglobin and the 
color loss would seem proportionately greater than 
the cell loss (chlorotic type of anemia.) There is a 
great variation in the number of leucocytes, with an 
occasional decided leucocytosis not clinically expli- 
cable by complications or otherwise. It is interest- 
ing to note that numbers 1, 2 and 3 in the table are 
the same individual, before and after arsenical treat- 
ment; and likewise 4 and 5 are made in the same 
individual; 19, 20 and 21 are also of interest as 
doubtful or cured cases. 



210 PET J. AGRA 

Differential leucocyte counts were made in several 
of these cases. The results generally showed a rela- 
tive, large mononuclear increase with an absence of 
eosinophilia, except in cases with such complications 
as round worms or hookworms. We do not tabulate 
these counts, as we do not find the work satisfactory 
and distrust the results. The general literature of 
pellagra is somewhat discordant as to results 
obtained in differential, leucocyte counts. A major- 
ity of workers report, however, a relative, large, 
mononuclear increase, with an absence of eosino- 
philia. 

With regard to qualitative changes in the red 
cells, we found the ordinary changes of a secondary 
anemia, the degree of such changes depending, of 
course, on the grade of the anemia. 

In bacteriological work on the blood, both by cul- 
ture and with animals, our work has been uniformly 
negative. We have followed Tizzoni's technique 
repeatedly in the attempt to isolate his streptobacil- 
lus pellagrae, but have met with no success. 

From a review of the literature, and from our 
own work, it would seem to us that secondary 
anaemia is a frequent, though not constant, condi- 
tion in pellagra; that leucocytosis is not often seen 
and is probably not a phenomenon of the uncom- 
plicated disease; that conclusions from differential, 
leucocyte counts, at present, are uncertain, but that 
there is probably a relative, large, mononuclear 
increase; that no protozoal parasite has yet been 
found in the blood; and that both by ordinary cul- 
ture methods and with animals the blood is found 
sterile.] 



THERMIC PHENOMENA 211 

Thermic Phenomena: Bonfigli, who regards 
pellagra as due to inanition, has found fever in 20 
per cent, of his cases. The temperature is oftenest 
found normal except in the tetanic or so-called florid 
forms. 

Alpago-Novello, at the hospital of Feltre, studied 
100 cases in which he took axillary temperatures 
morning and evening, leaving the thermometer fif- 
teen minutes alternately on the right and on the left 
sides. Of the 100 pellagrins there were 63 men and 
37 women; two were less than 20 years old; 39 were 
from 20 to 50 years old; and 59 were above that. 
Six were in the first period of disease, 35 in the 
second and 59 in the third. Control observations 
were made in ten hospital patients suffering from 
non- febrile maladies. Among the ten control cases 
1,607 observations were made. They showed a 
minimum of 35° C. and a maximum of 38.5° C, 
and this occurred once only, being probably caused 
by constipation, and disappearing promptly after 
purgation. The average temperatures in the ten 
controls were : in those above normal 37.38 ; in those 
normal 36.58; and that of the entire series 36.60, 
which, as will appear, is .35 of a degree less than 
the same average in pellagrins. 

Altogether on the 100 pellagrins 22,274 individual 
observations were made, which oscillated between a 
maximum of 41.5 degrees and a minimum of 35 
degrees. Above the normal temperature there were 
2,059, below the normal there were 5,251. Thus, 
then, the former made 9.24 per cent, and the latter 
23.57 per cent, of those that varied from the normal. 



212 PET J. AGRA 

Of the temperatures above the normal, 2.11 per cent, 
were taken in the morning (471) and 7.13 per cent, 
in the evening (1,588). In twelve pellagrins only 
out of the 100 was there no abnormal increase of 
temperature (one in the first period, ten in the 
second, and one in the third). The average temper- 
ature in all the cases was 36.95 degrees ; the average 
of the febrile temperatures was 37.96 degrees, only 
one degree higher than that of the average of the 
total observations. 

It may be concluded, then, that the average tem- 
perature is higher in pellagrins than in the control 
cases. In 88 per cent, of the cases it reached a febrile 
state and in some a high degree of fever. The eleva- 
tion of temperature takes place rather in the evening 
than in the morning. 

The condition of the pellagrous patients accord- 
ing to their temperature and the period of their dis- 
ease furnishes the following facts : 

In six cases of the first period, temperatures above 
the normal were found only 17 times, or 3.82 per 
cent. The maximum was 39 degrees, but it showed 
itself only one time and did not return. In another 
case the elevation did not go over 38 degrees. In 
all the other cases it remained below this figure. 
The average of all the experiments in this period 
of the disease was 36.72 degrees. In one case only, 
consequently 16 per cent., was there no febrile tem- 
perature. 

In the 35 cases of the second period, there were 
6.01 per cent, above the normal, or twice as many 
as in the cases of the first period. In one case the 



TEMPERATURE 213 

temperature rose to 39.4 degrees, in another to 39 
degrees; in 14 cases it oscillated between 38 and 
38.9 degrees; in 19 cases it was below 38 degrees. 
The average of all was 36.81 degrees, or 0.09 of a 
degree higher than the average of the cases of the 
first period. There were ten cases without a trace of 
febrile temperature, that is 28.57 per cent. 

The tendency to a febrile state is more accentuated 
in the third stage. Of these there were 59, and the 
temperature was found above normal 1,745 times, 
which is 10.12 per cent, of the total observations, 
being nearly double that of the second stage. The 
highest temperature observed was 41.5 degrees; the 
others were as follows: 40 degrees and above in 11 
cases ; 39-40 degrees in 23 cases ; 38-39 degrees in 17 
cases ; below 38 degrees in 8 cases. The average of all 
the observations was 37.06 degrees ; it was, therefore, 
more elevated by a quarter of a degree than the 
average of the cases of the second stage. A single 
case, that is 1.7 per cent., showed no fever, but still 
it ought to be stated that this case reached the max- 
imum of the normal temperature, that is 37.4 
degrees. 

An observation which may have a certain prog- 
nostic interest, is that the twelve patients whose tem- 
peratures had not been above normal during their 
stay at the hospital, left it cured with one exception, 
and this one case showed no improvement. Analo- 
gous results are obtained by observing the cases at 
different stages. 

The temperature increases during the passage 
from the first to the second or from the second to the 



214 PELLAGRA 

third stages. For example, in one case the highest 
temperature in the first stage was 37.5 degrees with 
an average of 36.98 degrees; in the second stage the 
highest was 38.1 with an average of 37.14 degrees. 
So, in another case, the second stage was afebrile, 
with an average of 36.60 degrees, while in the third 
stage there was a maximum of 40 and an average of 
36.82 degrees. But even in the course of a single 
stage in a febrile case, Alpago-Novello was able to 
assure himself that the improvement of the patient 
proceeded pari passu with a gradual decline of the 
temperature. And he was able to state that vice 
versa, the aggravation of the disease proceeded step 
by step with the rise of the temperature. This accords 
with the experiments on dogs in which the aggrava- 
tion of the symptoms of intoxication occurred at the 
same time with the maximum of temperature and 
minimum of weight. 

Of the 38 pellagrins who died of the disease, 28 
had in their last days a febrile temperature ; nine did 
not. Likewise with dogs, temperature elevation runs 
parallel with diminution in weight, and increases at 
the approach of death. 

The course of pellagrous fever is absolutely irreg- 
ular. It is rarely continuous, is often remittent, 
almost always with an evening rise; it is frequently 
intermittent (the rise usually occurring in the even- 
ing), and there is always a great irregularity both 
in course and in elevation. Often there is a fever 
disturbance at varying intervals. In the cases of 
typhoid pellagra Lombroso and CBelmondo have 
noted some rare conditions of subnormal temper- 
ature (33 degrees) in the last days of the malady. 




Plate II. 



inois case. Pellagrous "glove." Courtesy of Dr. G. A. 
Zeller. 



URINE 215 

Roncoroni and Lombroso followed attentively 
three patients for five days and the difference in the 
sides was almost regularly .1 to .2 of a degree, and 
in two cases especially a higher temperature was 
noted on the left axilla. In another series of 
observations of 12 pellagra patients the tempera- 
times on the left; twice only it was equal. [See 
charts.] 

Urine : Of 100 pellagra patients the quantity of 
urine in twenty- four hours showed an average of 
900 c. c, with a minimum of 500 c. c. and a maximum 
of 1,900 c. c. The quantity is, therefore, less than 
normal. Calderini also found in 35 per cent, of his 
pellagra patients a great diminution of the quantity 
of urine. The reactions of the urines of pellagra 
patients show a marked difference from the normal. 
In 100 cases the urine was: 76 times slightly acid; 
14 times neutral ; 10 times alkaline. It is in the most 
severe cases that the urine is more often alkaline 
(paralytics and aged patients) ; but also in young 
patients having cataleptiform or epileptiform 
attacks Calderini has made the same observation. 
Also in an examination of 33 cases, he found 21 per 
cent, of the urines strongly acid, 57 per cent, of 
slight acidity, 12 per cent, neutral, and 9 per cent, 
alkaline. Verga found 11 per cent, of the urines 
alkaline and 21 per cent, neutral. The color of the 
urines is constantly pale yellow, never passing the 
numbers 3 and 4 of the Vogel scale. The specific 
gravity is always less than the normal; it varies 
between 1,005 and 1,010, and between 1,018 and 1,025. 



216 



PELLAGRA 



A remarkable peculiarity of the secretion of urine 
is its constancy; even at the approach of death 
pellagra patients show very little change in the 
quantity, color and reaction of the urine. And in 
pellagrous meningitis and typhoid pellagra one 
finds, with a pulse of 120 and a temperature of 39 
to 41 degrees, the specific gravity of the urine is 
often less than normal. Roncoroni has examined 
the constituents of the urine in three cases, partic- 
ularly with regard to the urea (by Esbach's 
method), the phosphates and the chlorides. As a 
means of control the urine of three epileptics, while 
free from attacks, was taken. The persons under 
observation were placed under the same regimen. 
They were put on a daily diet equivalent to 147.41 
grams of albumen and casein, 567.27 grams of fats 
and carbohydrates, 22.891 grams of proteids, and 
48.913 grams of urea. The observations were con- 
tinued for ten days. The average results were: 




Weight in kilograms 

Urine in cubic centimeters 

Specific gravity 

Total urea 

Urea per kilogram of body weight 

Total phosphates . 

Phosphates per kilogram of body weight 

Total chlorides 

Chlorides per kilogram of body weight. 



52.43 

1,135.00 

1,014.50 

21.74 

0.41 

0.985 

0.018 

10.16 

0.20 



60.10 
1,303.00 
1,018.07 
26.40 
0.43 
1.692 
0.027 
11.43 
0.185 



In pellagrins the total amounts of urine and the 
specific gravity were diminished. The quantity of 



URINE 217 

urea was appreciably less than the normal in both 
epileptics and pellagrins, but in the latter this was 
more pronounced. On the other hand, in relation 
to the body weight, the urea was notably greater in 
the epileptics. 

We can say almost as much of the chlorides; the 
total quantity of these is likewise less, but estimated 
per kilogram of the body weight it is a little higher 
in the pellagrous than in the epileptics. 

A notable difference is to be found in the quantity 
of the phosphates. While the epileptics, during the 
time that they are free from attacks, eliminate an 
average of 1.692 grams of phosphates in twenty-four 
hours, or 0.027 gram per kilogram of their weight, 
the pellagrous, on the other hand, eliminate only 
0.985 gram or 0.018 gram per kilogram of body 
weight, that is, less than half the quantity of the 
phosphates eliminated normally, which is estimated 
at 2 to 3 grams in twenty-four hours. 

The difference is very perceptible between the per- 
centages of urea and of phosphates eliminated in the 
urine of pellagrins and in that of epileptics, which 
is respectively 4.36 and 6.45. 

Notwithstanding the rich diet which was given to 
the pellagrous patients under observation, the 
changes in nutrition were marked. 

Out of 110 urines of pellagrous patients albumen 
was found only twice by use of the usual reagents, 
six times by heat and nitric acid no trace of albumen 
was found, but cylinders were revealed by the 
microscope. In one case they appeared for several 
days and then disappeared completely. In general, 



218 PELLAGRA 

albuminuria is rare in pellagrous patients. It is not 
thus in the Tyrol; in fact, Dalla Rosa found at 
Trente that almost half of his cases had album- 
inuria. The urines of the pellagrous give on the 
addition of sulphuric acid a pronounced reaction of 
urochrome. The sediment of the urines of pellagra 
patients is composed of the following substances in 
the order of their frequency: triple phosphates, 
urate of ammonium, calcium oxalate, sodium urate 
and uric acid. This preponderance of alkaline salts 
explains the frequent alkalinity of urine. 

A female patient of Regis refused food for a time, 
but later she ate voraciously, while at the same time 
she had a diarrhea. Here are two analyses of her 
urine : 

Quantity in liters 0.148 0.450 

Specific gravity 1.021 1.014 

Reaction Acid Acid 

Color Yellow Yellow 

Urea, grams per liter 11.40 8.7 

Total phosphoric acid (in Pa Os.) 

grams per liter .. 1.30 0.45 

Chloride of sodium, grams per liter. 17.30 13.60 

[We have found indican almost constantly in the 
urine, and albuminuria has not been rare in our 
experience. J. J. Watson, examining the urine of 
12 patients 180 times, found indican present 175 
times.] 

Typhoid Pellagra: In considering this very 
grave complication, so peculiar to pellagra, it is 
necessary to avoid confusing it in any way with 
typhoid fever, as was done by Lussana. 

The earlier physicians, particularly Nardi, showed 
that there exist notable differences between typhoid 



TYPHOID PELLAGRA 219 

fever and typhoid pellagra. The latter has no pro- 
dromal symptoms and its course is much shorter; 
it affects the more robust ; it has no rose spots ; rarely 
ends in recovery; is always accompanied by a loss 
of strength proportional to the duration of the 
malady ; and many times, rather than the appearance 
of new symptoms, presents an aggravation of exist- 
ing phenomena. Finally, there is wanting in typhoid 
pellagra, as Verga pointed out in a letter to Billod, 
the changes in Peyers patches and Brunner's fol- 
licles; furthermore, the spleen is not only not 
enlarged, but is often smaller than normal. 

There are, moreover, still more notable differences 
in the symptomatology. In the beginning of the 
disease in these cases one sees not only the dry 
tongue, prostration, muttering delirium, carpho- 
logia, subsulti, intense thirst and the tremor of 
typhoid fever, but furthermore, strong retraction of 
the head, epileptiform or tetanic attacks, staring 
and brilliant eyes, paralysis of the bladder, edema 
of the extremities, dysphagia, stupor, vomiting, 
refusal of food, especially meat, or wolfish voracity — 
all lacking or rare in typhoid fever; also an invet- 
erate diarrhoea with ammoniacal odor and the same 
odor in the sweat and breath; urine alkaline or 
neutral, with low specific gravity ; and a temperature 
of 39 to 42 degrees, which is manifested frequently 
in the first days of the illness, while in typhoid fever 
the temperature reaches its maximum in the second 
week. 

Belmondo, who has made a special study of this 
condition, says: "It is rare that typhoid pellagra 



220 PELLAGRA 

develops suddenly, for, as a rule, the ordinary symp- 
toms of pellagra show a characteristic intensity ; the 
enteritis and the nervous phenomena (neurasthenia 
and paresis) as well as the general weakness 
assume an unwonted importance, and even on the 
psychic side there are a clouding of consciousness, 
depressed tone and a tendency to suicide. 

"Most of the cases are poorly nourished and at 
times much emaciated; however, there are others in 
which the panniculus adiposus is abundant and the 
general development of the muscles remains almost 
normal. There is often almost absolute unconscious- 
ness; at times, verbigeration, or visual hallucina- 
tions of a terrifying nature; if the patient is still 
able to express himself he believes he is sur- 
rounded by tormenting flames, (sometimes, also, 
there is even a true erythropsia), or feeling himself 
falling from a great height, he crouches in despera- 
tion on his bed praying for relief. 

"The entire musculature is in a very pronounced 
state of tonic contraction, and there is marked 
rigidity evident on making passive movements of 
the extremities. In these manifestations the reflex 
rigidity increases and generally the passive move- 
ments ultimately become impossible. Often the 
patient makes spontaneous, incoordinate movements, 
especially with the hands and arms from time to 
time. In these movements, apparently intentional, 
there is shown frequently a tremor of the upper 
extremities with wide oscillations and a certain 
grade of ataxia. The speech is drawling, the voice 
trembling and often nasal. 



TYPHOID PELLAGRA 221 

"The face has a rigid and contracted appearance ; 
however, at intervals the mimic muscles, principally 
those of the mouth, are agitated by tremors which 
spread from one muscular fasciculus to another and 
reach even distant muscles. 

"The lower extremities are habitually in forced 
extension, the feet in plantar flexion. The exagger- 
ation of the reflexes increases up to the last hour of 
life, the knee jerks being especially exaggerated. 
Even a definite ankle clonus is not rare. Under a 
light percussion on the tendon of the quadriceps there 
is often a spasmodic reaction of the leg accompanied 
by convulsive movements of the whole body. At 
times, together with the plantar clonus, there is a 
paradoxical contraction of the extensors of the foot, 
and hyperesthesia to factile stimuli so marked that 
a breath of air or a ray of light may provoke motor 
disorders or tonic convulsions." 

Typhoid pellagra differs from typhoid fever 
notably by the frequent presence of a large number 
of cylinders in the urine and the appearance of a 
large quantity of urea in the blood. 

Vassale has drawn attention to the great fre- 
quency in pellagrins of a form of chronic parenchy- 
matous nephritis, which is marked by desquamation, 
tubular degeneration and numerous cylinders. In 
six cases of typhoid pellagra he found, besides the 
renal alterations, viscereal congestions and enlarge- 
ment of the mesenteric glands, also a streptococcic 
bronchopneumonia. 

More important still, Belmondo, in twenty cases 
of typhoid pellagra, found cerebral and spinal 



222 PELLAGRA 

meningeal injection with infiltration by leucocytes, 
and extensive punctate hemorrhages in the cord; 
also many degenerated fibers in the cord, with the 
usual degeneration of the crossed pyramidal tract — 
lesions more common to meningitis and myelitis. 

From all this the conclusion may be drawn that 
the symptoms of typhoid pellagra resemble the 
symptoms of tetanus in the general increase of the 
reflexes and the spastic-tonic convulsions; typhoid 
pellagra seems, then, to be an acute exacerbation of 
the ordinary spinal lesions of pellagra. This exacer- 
bation can be attributed sometimes to uremic com- 
plications, or sometimes to an associated infection; 
but, above all, to an intensive influence of the poisons 
of corn on the spinal cord, either by cumulative 
effect, by greater quantity, or by higher toxicity of 
the material ingested. The pathogenesis, therefore, 
of the fatal tetanic state which can be produced in 
animals by subcutaneous or internal administration 
of certain preparations of corn, is in accord with 
the symptoms of pellagra, which may be typhoidal 
or may be more attenuated. 

The uremic complication of typhoid pellagra 
presents symptoms allied to those of renal disease 
rather than of typhoid fever ; for example, diarrhea, 
vomiting, refusal of food, ammoniacal odor, somno- 
lence and epileptiform attacks. But the quantity 
of albumen in the urine in these cases is frequently 
very small, so that the diagnostician should be on 
his guard. In some cases the symptoms of typhoid 
pellagra are not caused by urea, but by ammoniacal 
products in the blood, and for this reason they are 



MOTILITY AND SENSIBILITY 223 

marked by diarrhea, paresis, ammoniacal perspira- 
tion and alkaline urine. 

["We have observed in South Carolina this class- 
ical picture of typhoid pellagra occasionally; and 
we have also seen other grave, acute manifestations, 
(acute delirium) usually ending fatally, but usually 
without the convulsive phenomena. This has already 
been discussed elsewhere.] 

Motility and General Sensibility: Anomalies 
of the functions of the muscular system, especially 
muscular weakness, form in the early stage a part 
of the classic symptomatology of confirmed pellagra. 
By the dynamometer one obtains, on an average, 27 
kilograms in the case of men (50 cases) and 19 
kilograms in the case of women (50 cases). How- 
ever, in three cases of chronic pellagra in men the 
dynamometer marked 40 kilograms, and two 
women brought it up to 35, figures in accord with 
the normal. Therefore, it is evident that one would 
not be able to base a clinical diagnosis of pellagra 
absolutely upon the diminution of muscular force. 
There are, too, cases in men, robust and advanced 
in years, who show, apparently, at the beginning of 
the malady increased muscular power; but this is a 
subjective feeling which it is necessary to verify 
with the dynamometer. One really meets with pella- 
grins, who not only appear in good health but who 
endure the hardest work of the fields. Still, as Bel- 
mondo remarks, often when the strength of the arms 
persists there is paresis of the legs. The collected 
anamneses agree almost entirely in emphasizing the 
nervous symptoms which, after the appearance of 



15— p. 



224 PELLAGRA 

the tnthema and of the diarrhea, are observed in 
the po^agrous, and are manifested by great feeble- 
ness of the lower extremities. Tonnini says that the 
paresis of the pellagrous never attacks the muscles 
of respiration or those of the face alone. 

Spastic Paresis: In pellagra in an advanced 
stage there are two particularly striking symptoms : 
a very frequent extreme paresis of the lower extrem- 
ities which is in strong contrast with the increase of 
muscular tone and reflex musculo-tendinous excita- 
bility. It is a true spastic paresis. 

Tremor: "Tremor occurs in pellagrins," says 
Strambio. According to Belmondo, there is inten- 
tion tremor like that of disseminated sclerosis, more 
marked in the upper extremities, particularly in the 
fingers, than in the lower. At the same time, there is 
a lack of co-ordination made apparent by uncer- 
tainty upon standing with closed eyes. In the lower 
extremities these symptoms are less accentuated. In 
all cases it is more difficult to determine because of 
the contemporaneous paresis and reflex muscular 
rigidity. Sometimes there is tremor of the head and 
of the tongue as well. 

Contractures: In general there is in the move- 
ments and the attitude of the pellagrous a tendency 
to certain contractures ; many of these patients when 
they wish to rise do so with great difficulty, or 
wishing to extend the arm it remains rigid and semi- 
flexed. Many are accustomed to remain constantly 
drawn up. They squat down, the knees pressed 
against the chest and abdomen, clinging to some 



CONTRACTURES 225 

object with hands or feet or even with the teeth. 
Often these grotesque attitudes bring stigmata and 
characteristic deformities. 

In the case of one woman the skin was cadaverous 
and covered with telangiectases, the chestnut brown 
hair scattered over with white and reddish spots, a 
rude beard, cranium ultra-brachycephalic, nose flat, 
teeth of the upper jaw worn away by constant fric- 
tion, and from this cause, doubtless, a varicose 
nodule had formed on the tip of the tongue; emo- 
tional reaction was feeble, but not abolished ; tactile 
and painful sensibility was very much diminished; 
she was resistant ; mentally she presented the picture 
of dementia precox of the depressed type and was 
mute ; hid herself in fear in the most retired corners 
of the room or yard ; if any one succeeded in making 
her talk, she did not seem to be deluded but begged 
others about her to have pity on her misery, and 
was grateful for attentions received, of which she 
thought herself unworthy. All her inclinations and 
all her psychic activity expressed themselves in the 
most extreme muscular contractions. She sought 
the most favorable positions for contortions while 
hanging to slats and bars to which she clung even 
with the teeth, the tongue and toes. She gave as an 
explanation that she could not do otherwise. These 
symptoms continued up to her death, from tuber- 
culosis, although in the last few days she uttered 
monosyllables — "good, bad, your kindness, so much 
misery, etc." But up to the last day she continued 
to conceal herself as much as possible under the 
cover and to cling with her feet to the bars of the 
bed. 



226 pet j, agra 

Muscular Spasms and Tetanic Convulsions. 
It is comparatively rare to see in pellagra a partial 
chorea or that peculiar tendency of running in a 
straight line, but it does occur, more especially in 
the morning hours; there is then something which 
reminds one of epilepsy with ambulatory auto- 
matism. Besides, epileptiform attacks themselves 
are not rare. 

In typhoid pellagra there are contractions alter- 
nating with clonic spasms of the face and the 
extremities; they remind one of electric chorea or 
tetanus and are provoked and aggravated by sensory 
impressions. 

A very common phenomenon, especially in sum- 
mer, is that of pellagrins falling forward, backward 
or sidewise in consequence of vertigo and of sud- 
den tetanic movements, such attacks being called by 
the people "pellagra spells." Calderini reported 
cases of vertigo in 75 per cent, of the men and 77 
per cent, of the women. 

General tonic spasms with trismus and subsultus 
appear under the influence of light tactile stimuli 
in many patients, just as in experimental animals. 
The opening or shutting of a door, the noise of an 
electric bell will sometimes provoke these spells. In 
one case tetanic rigidity persisted even during sleep, 
with elevation of temperature to 39 and 41 degrees. 
As long as they walk and eat patients have the sen- 
sation of a cord stretched across the back which 
draws them forward or to the side and they bend in 
that direction. These attacks, because light and 
fleeting, might be called opisthotonic, emprostho- 



TENDINOUS PHENOMENA 227 

tonic and pleurosthotonic tetanus. "The convul- 
sions often have the appearance of tetanus," says 
Allioni. Often contractures of flexion and extension 
result from them; some of them extend their arms 
in the form of a cross and remain rigid from four 
to six minutes; others remain whole weeks with the 
limbs extended and rigid, like katatonics; others 
have the sensation of a force which draws them by 
the head or obliges them to stiffen out the legs 
(Nardi). 

Tendinous Phenomena. The patellar reflexes, 
as observed by Roncoroni, were always rather exag- 
gerated than feeble, as also reported by Alpago, 
Raggi and others. Out of 146 cases the knee jerks 
were exaggerated in 65 cases and feeble or absent in 
30 cases, normal in 50 cases. The exaggeration is also 
observed in dogs treated with the poison of corn and 
differentiates pellagra from ergotism. 

Tuczek found among 300 pellagrins the knee jerks 
exaggerated 200 times; in 23 there was at the same 
time ankle clonus; in the others these peculiarities 
were wanting. Frequently there was a difference in 
the two sides. In the third period of the disease, 
according to Tonnini, the knee jerks are absent in 
10 per cent,, feeble in 15 per cent., marked in 25 per 
cent. Foot clonus was wanting in 30 per cent., was 
normal in 47 per cent., and exaggerated in 22 per 
cent. In 42 pellagrins, at other stages of the disease, 
the knee phenomenon was wanting in two cases, 
weak in three, exaggerated in six ; clonus was want- 
ing in 8 ; it existed without exaggeration in 28, and 
was exaggerated in 6. 



228 PELLAGRA 

The reflexes of the skin which Koncoroni studied 
in 8 pellagrins were normal in 2, elevated in 5 and 
absent in 1. The pharyngal reflex in the same indi- 
viduals was weak in 5, normal in 2 and lacking in 1. 
In nine other cases the cremasteric reflex was want- 
ing in 3, weak in 3, active in 1, and exaggerated in 2 
on the right side only. Foot clonus was wanting in 
7 out of 9, lightly present in 1, and very active in 
another. 

On palpation the muscles of the lower extremities 
exhibit a wooden firmness, with resistance to passive 
movements. 

The mechanical excitability of the muscles is also 
increased, and often there are idiomuscular contrac- 
tions. 
Electric Keaction or the Muscles and Nerves. 

This has been studied with Eoncoroni in four pel- 
lagrins, who had been for some years in the 
hospital of Turin, of whom three were in good 
physical condition. They did not display the reac- 
tion of degeneration and did not show any deviation, 
either quantitative or qualitative, from the normal. 
In one case only the electric excitability was notably 
less than in the others, which was probably due to 
profound denutrition. This is not without interest 
for differential diagnosis from polyneuritis, pro- 
gressive muscular atrophy, lateral amyotrophic 
sclerosis, transverse myelitis, and other diseases. 

The reaction of the flexors of the forearm is often 
greater than that of the extensors, as well for K. C. 
and An. C. as for faradic stimulation; rarely it is 
the same or lessened. The difference of one side over 



DYSPHAGIA 229 

the other is not more than 0.4 milliamperes for the 
galvanic and 6 milliamperes for faradic irritation. 

Tonnini also found a greater faradic excitability 
of the flexors. According to him a diminution of 
the faradic excitability even in the cases of spastic 
rigidity is found also in the third period of pellagra ; 
under certain circumstances this reaction might 
serve as a differential diagnostic sign from spastic 
spinal paralysis. 

Dysphagia: Dysphagia is met with in about 2 
per cent, of the cases. It is less rare in dogs under 
experimentation. Tonnini has found numerous cases 
of hysterical globus, and cites the case of a woman, 
who, when she swallowed, had the sensation of a live 
coal. Strambio mentions something similar, and this 
seems to be observed also in dogs, although their 
symptoms are difficult of interpretation. 

Gait: Belmondo found the gait of pellagrins 
slow and uncertain. Often, he states, the pellagrous 
walk with short steps, the knees half bent, the legs 
apart for a larger base of support. In severe cases, 
walking is not possible without the aid of a stick or 
the support of other persons. The sole of the foot 
is scarcely raised above the earth, and often the feet 
do not even leave the ground, and then, too, one 
observes the typical spastic paralytic gait. Ron- 
coroni, in his observations on fourteen cases, has not 
found these peculiarities. From his table it is seen 
that: 

1st. The length of the step in its active part is 
greater on the left side in ten out of fourteen pella- 



230 PELLAGRA 

grins, and greater on the right side in the four 
others. 

2nd. The length of the step, from the median line, 
is greater than the normal in eight cases; less in 
five cases. In one case greater on the right; much 
less on the left; in six cases the left foot deviated 
more than the right; while in seven cases the right 
foot deviates further; in a single case the variation 
from the median line was equal on the two sides. 

3d. The difference between the bilateral deviations 
is often notably greater than the normal; it is 
greater on the right in six cases and on the left in 
seven. 

In the greatest number of cases, however, the walk 
of the pellagrins is not sensibly changed ; the tracks 
are normal, the step regular. The deviation from 
the median line generally differs little from the 
normal. But often the deviation is not complete on 
the two sides in a series of steps. 

Sensibility to Touch and to Pain. 

Sensibility is often abnormal among pellagrins. 

The observations of Albertotti on thirty cases gave 

the following results with the esthesiometer : 
End of the finger: Separation, 2.2 mm. (normal 

2.1 mm.) 

Forehead: 15 mm. (normal 8.8 mm.) 
Back of the neck: 21 mm. (normal 10 mm.) 
Back of the hand: 28 mm. (normal 19.5 mm.) 
Roncoroni found in 12 cases of pellagra, as an 

average, at the end of the fingers, on the right side, 




Plate XIV. Illinois case. Unusual localization involving 
mastoid and frontal regions; bilateral. Courtesy of Dr. G. A. Zeller. 



SENSIBILITY TO TOUCH 



231 



2.70 mm. ; on the left, 2.85 mm. ; on the tongue 1.55 
millimetres. Tonnini found a diminution of the sen- 
sibility of touch in ten out of thirty severe cases. 

The experiments on the sensibility to pain by the 
faradic current induced by Lombroso's method 
were made in individuals in whom there was no 
trace of erythema, and it was diminished principally 
on the hands and on the back of the neck. Thus, 
while healthy males show signs of pain in the palm 
at a distance of 43 cm., from the Ruhmkorff coil, 
and females at 60 cm., the pellagrous scarcely dis- 
play pain in the palm at from 20 to 47 cm. 

Tonnini, in a similar series of experiments by 
Lombroso's method, obtained analogous results, as 
shown in the table below. 



Parts of Body 


51 


02 

fcn o 

S w> 


3 

o 

s 

u 
o 
3d 

5 


Ends of fingers 


54 
59 
60 
92 
94 
46 
54 


35 
41 
35 
90 
90 
29 
39 


19 


Forearm (internal surface) . . . . 
Forearm (external surface) .... 
Forehead 


18 

25 

2 


Nose 


4 


Palms 


17 


Back of hand 


15 





The diminution of the sensibility to pain observed 
among pellagrins is not found in the other insane, 
among whom it is generally increased, or, at least, 
normal. 

Out of thirty severe cases, Tonnini found five 
times a profound analgesia extending from the feet 



232 PELLAGRA 

even to the face, but greater in the lower extremities ; 
he found more or less analgesia fourteen times, and 
hyperalgesia four times. In forty pellagrins less 
severely affected Tonnini found two-thirds analgesic, 
and only two hyperalgesic. 

Hyperalgesia in pellagra is more common in 
florid types, and is accompanied by a decided ele- 
vation of the temperature. The cases are numerous 
in which, if they are touched, principally on the 
stomach or on the thorax, they begin to cry out, and 
at the least noise they start; others have painful 
paresthesia?, as if water were thrown on their heads, 
or as if they were pricked on the legs by thousands 
of pins; they complain also of burning in the eyes, 
in the nose and in the face. Insensibility to pain is 
often shown by their voluntary exposure to cold as 
well as to burning or scorching to which they 
repeatedly expose themselves. Tonnini found the 
sensibility to heat better preserved in the face than 
in the extremities. But sometimes cryesthesia is 
found. 

Vision. 

In five cases of pellagra observed by Roncoroni 
and Ottolenghi the sight was normal. Among ten 
the study of the visual field did not disclose anything 
worthy of note. In two other cases there was partial 
vertical homonymous hemiopsia. In five cases color 
vision was entirely normal. 

Taste and Smell. 

The sense of taste is little diminished ; four pella- 
grins being examined with strychnine sulphate 



ANOMALIES OF SENSATION 233 

could, on the average, detect the bitter taste in a 
1 to 243,000 solution (healthy individuals 1 to 500,- 
000). Saccharine was detected in solution of 1 to 
37,000 (healthy individuals 1 to 80,000). These 
same persons noticed perfumes in very dilute solu- 
tions (1 part of oil of carnations to 50,000 of water). 
They distinguished readily also quantitative differ- 
ences in solutions of perfumes but could not describe 
their nature. 

Anomalies of Sensation. 

A subjective sensation experienced with few 
exceptions always in the beginning of the disease, 
and lasting frequently to the end, is that of burning 
on the hands and legs, sometimes over the entire 
body. Others, on the contrary, experience a sensa- 
tion of cold or of heat internally and of cold in the 
extremities. 

Then there is frequently pruritus in the groin or 
on the back and arms ; some patients have abnormal 
sensations in the genital organs and in the anus, just 
as do some alcoholics; others believe that they feel 
hot water running down the back, or on the head, or 
have burning and itching at the nipples and in the 
inguinal region; when they are touched they think 
they feel prickings and twitchings, principally 
between the shoulder blades, in the thumb and 
on the soles of the feet. Sometimes this sensation 
extends all along the vertebral column, so that the 
patients cannot be covered in bed or dressed with- 
out great distress. Often they feel neuralgic pains 
in the arms, in the groin or in the thighs, and shoot- 



234 PELLAGRA 

ing pains which injections of morphine do not 
relieve. 

Frequent are the cases of cephalalgia, which 
increases if the sick remain on their feet or are 
exposed to the light of the sun. Once persistent 
hemicrania was noted, with increase of temperature 
on one side of the face and enlargement of the pupil 
of the same side. 

An intelligent female pellagrin, subject to fre- 
quent attacks of crying and continuous insomnia in 
the five or six days which preceded these attacks, 
had an invincible desire to sleep. Another lay down 
in the fields in order to sleep, and remained thus 
two or three days; she became angry when they 
wished to interrupt her sleep. This somnolence is 
sometimes persistent, and in one case it lasted two 
years. Insomnia, however, is more common even 
among pellagrins not mentally affected. 



CHAPTER VII 

Psychic and Paretic Phenomena, Complications, 
Heredity. 

It is not easy in the study of the psychic phe- 
nomena of pellagra to distinguish those symptoms 
produced directly by the disease from mere coinci- 
dences or accidental complications, more especially 
insanity. There are depressed mental states which 
arise from the pitiful and wretched condition of 
these pariahs of upper Italy. This condition can 
frequently be explained as a melancholia analogous 
to the melancholia db miseria of Lasegue. 

A notable peculiarity among pellagrins, even 
when not mentally affected, is an increasing irrita- 
bility; at the least inconvenience or on the slightest 
emotional disturbance they quickly display temper, 
although ordinarily they appear quite normal. 

This is a characteristic common to alcoholics and 
to paralytics in the early stages of their malady; 
and this can be explained by the law that any 
enfeebled organ is readily irritated and easily 
suffers. The laity, who consider these external signs 
only, frequently attribute pellagra to moral causes. 
Perversions of feeling are generally rare. 

Very often the patients complain of a loss of 
memory and of mental weakness, which diminish 
when they are in bed or lying down. Certain others 
indulge in introspection and analyze very acutely 
their mental troubles. The poor wife of a fisherman, 
ordinarily taciturn and apparently rather dull, 



236 PELLAGRA 

caused surprise in the course of her attacks by some 
rather remarkable observations, for instance: 
"Notice, now, these invalids, they have no hearts, 
they are full of superstitions, they use cards to learn 
whether their husbands will be true, as if the chance 
of cards could have such influence; then from the 
accidental fall of a card they draw conclusions by 
which they are irritated and plunged into quarrels. 
Is not this sickness rather than insanity?" 

Chronic pellagra is often accompanied by a hypo- 
maniacal state with a tendency to sarcastic speeches 
and caustic observations, a thing often seen among 
other insanities. Frequently the pellagrous psy- 
chosis appears under the form of a special melan- 
cholia, more often in the form of an insanity with 
systematized delusions. This last form may be 
observed in hereditary pellagra; vagaries of mem- 
ory, self-accusations, nosophobia, apprehensions of 
personal violence, delusions of pregnancy, loss of 
personality, and concealment of sex have all been 
noted. 

A woman of Seronno, 38 years old, confided mys- 
teriously to the judge that she had been violated and 
had become pregnant. She believed that she had 
given birth to a child, and then, with the help of 
her seducer, had buried it alive; for three months 
she led the officers of justice to many places in search 
of the little corpse ; when finally a medical examina- 
tion revealed that she was a virgin suffering from 
pellagra. 

In another case a male pellagrin imagined himself 
affected with venereal disease. He dosed himself 



PSYCHIC AND PARETIC PHENOMENA 237 

with remedies advertised in the newspapers, and at 
last complaining that all the world was pointing the 
finger of scorn at him, he threw himself into the 
water. 

Another sufferer, of sufficient intelligence to be 
employed in the care and instruction of convales- 
cents, imagined that he was going to marry in a 
short time a young and wealthy marchioness, and 
dissimulated his delusion with a finesse which is 
sometimes seen in the paranoiac state. 

A pellagrin in the hospital at Milan, besides the 
usual symptoms of pellagra, suffered from a cardiac 
affection accompanied by edema ; he displayed a true 
monomania of avarice, rigidly economizing his own 
food, at the same time striving to prevent others 
from eating. 

But these are exceptional cases, and, as Verga has 
noted, are probably only examples of a psychosis 
engrafted upon pellagra. 

In general, even when pellagrous mania assumes 
a type, it is rather that of systematized delirium 
than of paranoia. 

In almost all cases of pseudo-monomania there is 
associated a well nourished body, and this is another 
analogy with general paralysis. 

Another characteristic in pellagrous insairiy, is a 
real or, more often, apparent stupidity or an obsti- 
nate mutism. The sick stay motionless ill a crouched 
position, as if they sought to avoid not only social 
contact with other people, but even the light itself. 
When this apathy ceases, it may be succeeded by 
attacks of psychic epilepsy or often followed by an 



238 PELLAGRA 

active delirium ending in a ceaseless torrent of 
words. In other cases, instead of these depressed 
and sluggish phenomena, there may be observed a 
persistent gaity or an exaggerated activity. The 
patients repeat, without weariness, certain appeals, 
chants, phrases, sometimes with an insupportable 
tenacity, and resemble in this the stereotypy of 
dementia precox. 

Cases of hallucination are numerous, especially 
those having a strain of cenesthesia, and these have 
a certain dependence upon an abnormal state of the 
viscera. They burn, they have dogs in their 
stomach, they see water on all sides, and hear voices 
commanding them to drown themselves ; or, perhaps, 
they are aggressive, believing themselves insulted. 
The psychoses of pellagra do not show persistent 
paroxysms without interruption, they are rather 
short recrudescences and fleeting disturbances. 

The anarthria or brief aphasic attacks which 
are found in certain paralytics, alcoholics or epilep- 
tics, are not met with in pellagra. There is, how- 
ever, often an embarrassment of speech with a ten- 
dency to repeat certain words, and to pronounce 
phrases without connection. Two peculiarities which 
are more characteristic of pellagrous psychosis are 
sitophobia and hydromania. 

The most frequent form of psychosis in pellagra, 
according to Eegis, is mental confusion with depres- 
sive states or with delirium. It exists, more or less 
marked, in most of the cases. It manifests itself 
by inertia, passivity, indifference, torpor, frequently 
very marked; by insomnia, often with terrifying 



PSYCHIC AND PARETIC PHENOMENA 239 

hallucinations both of sight and hearing; by 
depressed delusional states with fixed ideas of 
despair, of damnation, of fear, of anxiety, of per- 
secution, of poisoning, of possession by demons and 
sorcerers (Warnock) ; by refusal of food, and a ten- 
dency to suicide, especially to suicide by drowning, 
so much so that Strambio has designated this feature 
of the disease by the name of hydromania. This 
melancholic depression, which may go in certain 
cases as far as stupor, is always accompanied by, or 
founded on, a certain mental obtuseness, even intel- 
lectual dullness, and considerable general anesthesia 
(Morichon, Beauchamp and Courtellemont), which 
finally becomes permanent and culminates gradually 
in a dementia which deepens in proportion as the 
pellagrous cachexia progresses. It may be accom- 
panied by polyneuritis (Kighetti). 

One may observe also in every severe chronic intox- 
ication a morbid state resembling general paralysis 
(pellagrous pseudo-paresis). This occurs especially 
in those cases in which, instead of the habitual 
melancholic ideas, the patients present ideas of satis- 
faction and wealth (Warnock, Marie). 

"Stupor," says Girma, "has been often mentioned, 
as well as ideas of suicide; in two cases the disease 
developed with alternations of agitation and depres- 
sion; twice there was an intellectual torpor, like 
dementia; three times trembling of the hands and 
of the tongue was noted, as well as difficulties in 
walking, difficulties of speech, and once paraplegia; 
these cases furnished a symptomatology somewhat 
similar to that of paralysis and we even make use of 



ift-p. 



240 PELLAGRA 

the term pellagrous pseudo-general-paralysis / once 
there were spinal and abdominal pains. 

"Deaths in pellagra have resulted: three times 
from cerebral congestion ; four times from pellagrous 
marasmus with diarrhoea; four times from pul- 
monary tuberculosis. These deaths followed upon 
a rather short stay — some months at the most — in 
the Asylum of Pau. 

"The cases which recovered progressed favorably 
rather than rapidly under a tonic regimen and their 
discharge took place in the course of the first year. 
Only two hereditary cases, with mental aberration, 
had to be detained longer ; one developed dementia ; 
the other, originally defective, was discharged at the 
end of three years 'improved.' " 

Refusal of Food. 

In many cases refusal of food is the result of per- 
verted innervation of the stomach, which shows 
itself by anorexia or voracious appetite. Such 
patients often say they feel a lump in the epigas- 
trium, and cannot swallow food (dysphagia). A 
female patient obstinately refused all nourishment 
during her insanity, and upon recovery ate on 
request, but with great repugnance. "It seems to me 
that I am filling up a body already full; I am full 
up to the neck." Constipation may sometimes 
explain this sensation of repletion. Repugnance for 
food may also be explained by other somatic causes 
or delusional ideas — fear of injury, of indignity, of 
culpability, etc. In other cases it may be due to 
hallucinations, such as visions of the host on plates 



PSYCHIC AND PARETIC PHENOMENA 241 

or fear of poison, but it is then only a partial sito- 
phobia. Eepugnance to food is sometimes due to 
negativism and resistance; if no notice is taken of 
such patients and they are left to themselves, they 
eat better. 

Suicide. 

The other condition, characteristic of pellagra, 
hydromania, has also variable and complex causes. 
In many cases there exists a real passion for water; 
and this is justified by the continuous burning sensa- 
tions which are relieved by effusions of cold water. 
u See," said a patient, "this water is my only salva- 
tion, if I were not able to bathe myself constantly 
these burning sensations would drive me to suicide. 
I would not give this water for all the treasures in 
the world." In rigorous winter weather some may 
even break the ice in order to plunge into the water. 
In other cases this tendency does not spring from 
sensations of burning, but seems due to the pleasure 
evoked in patients by the attraction of the shimmer- 
ing surface of the water. This peculiarity is related 
to certain modifications in the retina, and is seen at 
times in children and in some paralytics. 

On some pellagrins fire produces impressions 
similar to those of water; they may throw their 
effects into it, and even burn their own hair or beard. 
A gardener, forty-five years old, who suffered from 
pellagra with pruritus and a muscular feebleness, 
which compelled him to rest at least two days each 
week, used to say : "Nothing in the world gives me 
more pleasure than a little stream; when I take a 
walk I go alongside of it and look at it always as 



242 PELLAGRA 

long as I can. In the night I dream of seeing 
water." 

On the other hand, others have a great repugnance 
to water; the sight of it terrifies them. This 
repugnance is poorly interpreted by many observers. 
It may lead to suicide by drowning from a para- 
doxical attraction against which, at first, the patients 
try to struggle. For an accurate comprehension of 
this phenomenon it is necessary to analyze their con- 
fessions. "When I see water," said one patient, "my 
eyes are blinded and I am nauseated. If I cross a 
bridge, I am obliged to close my eyes, and try to 
walk in the middle, otherwise I should fall." "If I 
look into the water," said another, "I am obliged to 
close my eyes, and to hold on to a stake or to a tree ; 
if I do not, I feel myself attracted by the water and 
am likely to fall." "If I do not close my eyes at 
sight of water, it forces me to turn my head in its 
direction, and I cannot withdraw my gaze from it," 
etc. 

These two contradictory phenomena of attraction 
and fear are really not irreconcilable. Certain of 
these "hydrophobias" are marked by a fear of flow- 
ing surfaces because of photophobia. For others, 
however, actual contact is sometimes necessary, while 
still others cannot endure to drink any but hot 
liquids or the opposite. 

These sufferers certainly do not go into the water 
because of any predilection for it, quite the con- 
trary. Indeed, water, as does a mirror in certain 
delicate women, causes in some an overwhelming 
impression of disgust, or of repugnance or a vertigo. 



PSYCHIC AND PARETIC PHENOMENA 243 

One day, in fine weather, a patient being placed in 
front of a turning mirror, hid his eyes, drew back 
his head, and did not wish to look again, saying that 
it produced on him the same effect as water. Another 
patient, when placed before a mirror which reflected 
the rays of the sun, fell a few minutes afterwards 
in an attack and was nauseated. Many patients have 
a repugnance for water, notwithstanding the fact 
that it does not cause them to feel stupefied. Here 
again is seen evidence of the contradictory phe- 
nomena which are so often found in chronic intox- 
ications, especially in pellagra. Some even feel 
repugnance to cold water, and are obliged to heat 
it in order to drink. In Tuscany, pellagra is often 
the cause of many people not being able to endure 
hydrotherapeutic treatment. 

Many sufferers drown themselves not from disgust 
of life, but in obedience to hallucinations which 
probably arise in recollections of former agreeable 
impressions, associated with water. 

Suicides by drowning are numerous also by reason 
of a kind of motor automatism or instinctive impul- 
sion, similar to attacks in epileptics. They do not 
know why they throw themselves into the water, and 
if they survive, they can not explain their attempt. 

Certain patients throw themselves into the water 
not to drown themselves, but to find some relief from 
their torturing paresthesias, and being seized with 
vertigo, they are drowned. One pellagrin could 
neither go to stool nor urinate anywhere except in a 
ditch, the water of which alone could stimulate his 
enfeebled reflexes. 



244 PELLAGRA 

Finally, frequent suicides occur from a fixed reso- 
lution to escape from the sufferings of the malady. 
In the execution of their attempts they derive aid 
from a profound perversion of sensibility, which, 
while it makes them painfully aware of certain 
impressions, arising from the stomach and heart, 
renders them, on the other hand, less sensitive to 
trauma and other more painful things. Thus a 
pellagrin, who suffered intolerable pains in the 
epigastrium, cut his throat with a sickle, and then 
dragged himself 100 metres to his house with his 
sickle in his hand. 

It appears, then, that when death by drowning 
occurs among pellagrins, there is always doubt as to 
whether it is accidental or suicidal. 

Statistics show that in those provinces of Italy 
where pellagra is prevalent, suicides by drowning, 
voluntary or accidental, are more numerous than in 
the provinces whose inhabitants, by the nature of 
their work, or by the mere situation of their habita- 
tion near the water (Naples, Sardinia, Liguria), are 
more exposed to drowning. It follows that in dis- 
tricts like Lombardy and Emilia, where there is 
much pellagra, almost half of the suicides occur by 
drowning. On the contrary, Tuscany, Komagna, 
Naples and Sicily, which have a numerous popula- 
tion of fishermen, and are half surrounded by the 
sea, have a small number of such suicides in com- 
parison to population. 

These facts would become still more obvious if the 
deaths by accident are compared with those by 
drowning in various regions or provinces, though 
there are exceptions. 



psychic and paretic phenomena 245 

Intermissions. 

A remarkable peculiarity of pellagra, that is well 
known, is the intermittent appearance of the psychic 
symptoms. 

The rare attacks during cold weather are almost 
doubled in the months of spring. They become par- 
ticularly numerous in the month of March, and 
increase with the heat up to July. The number is 
small in the spring and increases again in autumn 
(September). 

For more exact observation a record was kept of 
severe psychic exacerbations in 100 pellagrous insane 
during a period of five years ; the averages are given 
in the table below : 

Dec. Jan. Feb. Men. April May June July Aug. Sept. Oct. Nov. 
Attacks 33 34 27 50 54 67 77 88 46 81 66 48 

There are two causes for this. The influence of 
the elevation of temperature, but still more, the rapid 
therm ometric and barometric changes. The attacks 
of autumn are those which demonstrate this. Other 
observers, as Calderini, have remarked that in many 
cases of pellagra, the relapse of psychic troubles took 
place in the autumn instead of in the spring. 

Spring recrudescences are also observed in endemic 
alcoholism. It is possible that these symptoms 
depend on the deficiency of certain mineral salts in 
the blood, for example the phosphates, which are 
diminished in the first cold months, more exactly in 
the proportion of 0.569 to 1.064, in comparison with 
the winter months. 



246 PELLAGRA 

In six cases a tertian type of recrudescence was 
noted. For example, M. G\, thirty- seven years old, 
refused nourishment for a day, pulse 90 and tem- 
perature 37.5 C. degrees ; the following day she was 
entirely herself, pulse 80 and temperature 36; the 
third day she was delirious again, with increased 
temperature and pulse rate. 

Another periodicity common in pellagra is of a 
diurnal type with recrudescences at certain hours. 
Almost all the patients say that their headaches are 
more violent between midday and three o'clock, 
during the hours of the greatest heat. Others declare 
that they have vertigo all night, and hallucinations 
before falling asleep, whereas during the day they 
feel well. 

Development. 

From the standpoint of the evolution of the indi- 
vidual, certain pellagrous psychoses are character- 
ized by an arrest of development (denied by Fer- 
rario) ; a kind of hebephrenia with genital and gen- 
eral insufficiency; numerous examples of this have 
been cited (hereditary pellagra and infantile degen- 
erations). 

Complications. 

Pellagra may be complicated with many other dis- 
eases, which sometimes mask it completely. The 
most common of these is alcoholism. 

(a) Alcoholism. 

The question whether certain symptoms come 
from alcoholism or from pellagra, is, at times, very 




m 




PSYCHIC AND PARETIC PHENOMENA 247 

difficult to decide. This arises in part from the fact 
that many incipient pellagrins, like paralytics, seek 
a passing solace in alcohol. Others are obliged by 
their expenditures in alcohol, to buy for food spoiled 
corn, which is, of course, cheaper. 

Small quantities of alcohol used by others, already 
predisposed to the disease by the poisons of corn, 
easily precipitate the malady just as might be done 
by other secondary causes. These two factors are 
often coincident, and the sufferer, not willing to con- 
fess his vice, leads the physician into error. 

A pellagrin of Verona said he made from five to six francs 
per day as workman in a factory, and was obliged to quit 
his work because of his malady; he was, as a matter of 
fact, sent away for drunkenness and was obliged to beg his 
bread; he was a hardened drinker who sold the bread he 
begged in order to buy brandy and spoiled polenta. Since 
then he has suffered from muscular feebleness, trembling, 
diarrhea, pruritis, epileptic attacks, weakness, want of appe- 
tite and dilatation of the capillary vessels of the face. 

Another drunkard, who also ate spoiled polenta in order 
to be able to procure brandy, suffered, at fifty-four years of 
age, with severe headaches, marked feebleness of the legs, 
vertigo, constipation, desquamation of the hands, burning 
pains on the soles of the feet, and, later, ptosis, trembling 
and convulsions of the right hand with slow pulse and 
atheroma. 

The Piedmont Commission, as well as Paolini 
at Bologna, noted frequently the coincidence of 
pellagra and alcoholism. It is remarkable, how- 
ever, that in the years of rich wine harvests pel- 
lagra is rare. This contradiction disappears when 
one recalls that small quantities of wine are help- 
ful, while large quantities are injurious; and 



248 PELLAGRA 

that a lack of wine in many places means an absence 
of prosperity, and the necessity of eating poor corn. 
In general the cases in which alcoholism and pel- 
lagra are coincident seem less severe than those of 
pellagra alone; and all of these cases have been 
found in the cities. 

[According to Nicolas and Jambon, three classes 
of persons are subject to pellagra: those who eat 
corn, the insane and alcoholists. A similar idea is 
entertained by some Italians who call their cases true 
pellagra in persons who eat corn products, ethylic, 
in those who use alcohol and mixed in those who use 
both.] 

(b) Tuberculosis. 

A disease often complicated with pellagra is 
tuberculosis. It is very rarely found among the 
pellagrins of Venetia and Lombardy, but Delia Rosa 
found numerous cases of it in the southern Tyrol. 
He found in fifteen fatal cases of pellagra ten cases 
of tuberculosis. The rarity of a tuberculous compli- 
cation in upper Italy has been atttributed to an 
antagonism between tuberculosis and the cardiac 
affections to which pellagrins are often subject. 
Perhaps the old writers have confounded tubercu- 
losis with croupous pneumonia, which is frequent 
in pellagrins, as are also pulmonary edema and 
emphysema, especially in those with mental aliena- 
tion. 

(c) Syphilis. 

In Roumania, Felix found numerous syphilitic 
pellagrins, but this complication has not often been 
found in Italy. It is worthy of note, however, that 



PSYCHIC AND PARETIC PHENOMENA 249 

syphilis in certain parts of Roumania is very wide- 
spread in consequence of insufficient prophylactic 
measures. 

(d) Thyroid Disease. 
In the Lombardy districts where goitre and cre- 
tinism prevail, pellagra is widely spread; so much 
so that often relatives and physicians regard the one 
disease as the cause of the other. 

Atrophy of the thyroid gland is met with in the 
pellagrous, but it is still more frequent in the here- 
ditary cases with arrest of development. 

This seems to show the easy vulnerability of this 
gland to the poisons of corn, and helps to explain 
the dystrophic and myxedematus phenomena some- 
times observed. It may be added that this alteration 
of the thyroid seems of much consequence in aggra- 
vating certain symptoms of the pellagrous intoxica- 
tion. Pellagrous psychoses accompanied by thyroid 
disturbances are marked by signs of stupor; sito- 
phobia is also frequent in such cases, and cures are 
more rare. 

(e) Uterine Complications. 
Among the numerous complications there are also 
utero-ovarian diseases, and it is often impossible to 
distinguish whether these are accidental complica- 
tions, or are really essential phenomena of the dis- 
ease. [This subject is more fully discussed else- 
where.] 

(f) Marasmatic Degeneration. 

A very common complication is marasmatic 

degeneration, and a theory of pellagra has been 

based on it. The sufferers, especially if poorly 

nourished, even on full diet waste rapidly, and 



250 PELLAGRA 

finally show a great degree of emaciation, with a 
reduction in weight even as low as 28 kilograms. 
This emaciation, however, ceases in the winter 
months. It is generally accompanied by hydro- 
mania, persistent mutism, and rather frequently by 
hyperinosis. 

[Malaria, by some writers, is spoken of as a rather 
frequent and very important complication of pel- 
lagra. It has not been common in our experience 
even in the southern United States. Wood, from 
North Carolina, has, however, reported interestingly 
on this complication. 

Hookworms, round worms and other intestinal 
parasites have, in the South, been very common in 
our experience ; and, of course, add to the gravity of 
the outlook at times. 

The question of intestinal protozoa in pellagrins 
attracted much attention at the National Conference 
on Pellagra at Columbia, South Carolina, 1909. 
Much possible importance was attributed by Siler 
and Nichols to amebiasis, which they found very 
frequently present among insane pellagrins in Illi- 
nois. Allen also reported the frequent presence of 
amebse in the stools of pellagrins in North Caro- 
lina, as has Long, in South Carolina and Pennsyl- 
vania more recently. 

The opinions of these observers generally was that 
amebiasis should be regarded as a serious complica- 
tion of pellagra, and that such intestinal protozoa 
might have important effects by increasing intestinal 
irritation and modifying the absorption of endoge- 
nous toxines. Some recent students of pellagra seem 
to regard amebse as a possible cause of the disease. 



PSYCHIC AND PARETIC PHENOMENA 251 

In our experience, while we have found protozoa 
not infrequently in the stools of pellagrins, ame- 
biasis has been comparatively rare.] 

Diagnosis. 

So far as concerns the differentiation of true pel- 
lagra from alcoholism and from paralysis in its 
last stages, it is important to note that in pellagra 
there are wanting marked disturbances of speech; 
arterial atheroma is rare; the ambitious or melan- 
cholic delirium of paralytics is very rare. The urine 
does not show the density and abundance of phos- 
phates seen in that of alcoholics and paralytics, and 
the visual and tactile hallucinations of the drunkard 
do not occur. Alcoholics do not have hydromania 
nor atrophy of the heart nor the earthy complexion 
and faces observed in pellagra. 

Hereditary Pellagra. 

There are, however, forms of pellagra, or of 
pseudo-pellagra, most difficult to diagnose because 
the disease does not show itself in its full symptom- 
atology. This is designated as hereditary. Like 
hereditary syphilis there may be two types, one very 
severe, another very benign and mild. 

The first manifests itself about the second year 
of life. It is rarely accompanied by desquamation; 
most often there are epigastric pains, pyrosis, sito- 
phobia, unsteady gait, fears, diarrhea, yellowish 
complexion, as in malarial cachexia, retardation and 
arrest of development; later may be seen the com- 



252 PELLAGRA 

plete phenomena of a pellagra which resists all ther- 
apy. In some there are noted marked brachycephalia 
or dolichocephalia, with receding brow, ears badly 
set, facial asymmetry, anomalies of the genital 
organs or other physical stigmata of degeneration. 
In the districts where this form prevails, the benign 
form is also seen, and merits more study from the 
prophylactic and hygienic point of view. It is a 
true "pellagra sine pellagra" 

Many of these unfortunates are seen in certain 
sections of Venetia, and of Trentino, even among 
the well-to-do classes. They complain of burning 
at the extremities, of pains in the back, and of 
pyrosis. The women suffer from leucorrhea, uterine 
heaviness, amenorrhea, flatulence, vertigo, constipa- 
tion or diarrhea, and a yellowish color of the skin, 
but desquamative skin lesions and delirium are 
wanting. 

These complications move me more to compassion 
than does true pellagra, because they indicate how 
misfortune may occur through hereditary infiltra- 
tion into the germ of an entire population. It hap- 
pens with pellagra, as with cretinism, that the dis- 
ease once scattered in a group of families, predis- 
posed by locality, misery, etc., displays its taint even 
among families which might have been exempt, 
bequeathing them, if not the body, at least the livery, 
as Verga has well said, of this endemic malady. 
(Lombroso.) 

In Favrio it seems undoubted that heredity acts 
directly. All the alliances of the Franceschinelli and 
Lorenzi, for example, being afflicted with pellagra, 



PSYCHIC AND PARETIC PHENOMENA 253 

while the Briosi family, who live with equal par- 
simony, if not misery, are entirely exempt. 

Atavism. 

Many times hereditary influence, on the other 
hand, is not so evident, for atavism is displayed in 
the weak attention and the labile memory of the 
poor peasant, and may be indeed a preponderating 
force over paternal heredity. 

For instance, a young pellagrous girl, 16 years old, suffer- 
ing from typhoid pellagra, had had chronic diarrhea at the 
age of two years, and at eight years vertigo, later typhoid 
pellagra and insanity; she had healthy parents, but her 
grandfather had died of a pellagrous diarrhea at an ad- 
vanced age. 

In another case a boy of 12 years, of retarded develop- 
ment, with scaphocephalous cranium, suffered from a con- 
tinous diarrhea, with a tendency to bite; he also had the 
habit of striking his head against a wall, indeed so often 
as to cause an osteoma to form on the left side of the 
cranium, and he displayed an exaggeration of his sensory 
and motor reflexes. The father and mother were healthy, 
intelligent and sound, brothers pellagrous. The grandfather 
at a certain age, however, suffered from a tendency to bite, 
and would fall to the ground at the least noise: he also had 
the habit of beating his head against the wall just as his 
grandson had. 

"The descendant of the pellagrous is recognized 
by his vacillating and uncertain step; his muddy, 
yellowish sclerotics, his fixed look, the pale and 
ashy color of his face, his reddish eyelids, his hare- 
lip, the scant hair on his head, his brow prematurely 
furrowed, his flabby muscles, his stupid and apa- 



254 PELLAGRA 

thetic appearance. This general aspect is found in 
children of ten to twelve years and is the appearance 
presented by the children of pellagrous parents." 
(Sacchi.) 1 

The pellagrous intoxication of antecedents, and 
especially of the pregnant mother, is capable of pro- 
ducing in the offspring early and rapid exhaustion 
of vitality, degenerative changes and especially 
arrest of organic development. 

In hereditary pellagra there is a very high per- 
centage of mortality. The stigmata of degeneration 
are common, especially anomalies of the cranium, 
arrest and retardation of bodily development, even 
veritable dj^strophic infantilism, myxedematous 
dwarfism, or the exhaustion of the procreative 
power. 

"I remember very well that when wretched, scrof- 
ulous children presented themselves at my home, my 
father would say: 'It is the offspring of a pella- 
grin.' " (Sacchi.) 

Especially prominent among the descendants of 
old pellagrous families, are peculiar nervous 
troubles, manifested by sadness, depression, and 
suicidal tendencies most often carried into execu- 
tion by hanging. Hereditary pellagra may also be 
combined with an acquired pellagra. 

In France, pellagrous insanity, now almost un- 
known, still manifests itself under the form of 
hereditary pellagra, as the recent work of Regis 
shows. According to the statistics, the asylums of 
Pau and Montpellier are almost the only ones in 

Piedmont Commission, 1847. 



PSYCHIC AND PARETIC PHENOMENA . 255 

which this affliction exists. This shows that pellagra 
is only possible where corn is consumed. This cereal 
must needs enter into the daily food, a thing which 
happens only exceptionally in France, and then in 
the back country, among the miserable and desolate. 

It is not the same in Spain, where pellagrous 
intoxication persists in certain regions and affects 
sometimes even 20 per cent, of the population. 

In Italy, in spite of the valiant struggle of Lom- 
broso during all his life, the regions of Bergamo, 
Brescia, Venice, Padua, still number 35 to 50 pella- 
grins to 1,000 inhabitants. Treviso, Vicenza, Cre- 
mona. Pisa number 10 to 20 each per 1,000. At 
Milan the writer examined, some months ago, 
several insane cases of pellagra. The total number 
of cases in Italy is estimated at 72,000. [The esti- 
mate of E. A. C. Wollenberg (op. cit.) July, 1909, 
of the total number of pellagrins in Italy is less than 
50,000.] 

In Eastern Europe pellagra prevails, also in Rou- 
mania, Servia, Bosnia, Macedonia, Albania and the 
Turkish countries, as well as in Greece. 

The fine work of Babes and Marinesco in Rou- 
mania on the neuro-pathology of this intoxication 
is supplementary to that of the Italian school to 
which we owe the prophylactic measures of the law 
of July 21, 1902, which originated in the Anti- 
pellagra Congresses of Bologna, Padua and Milan. 
(See Appendix I.) 

In Egypt pellagra is spreading as in other Turk- 
ish countries, where corn is largely eaten. There, one 
can say that almost all the fellaheen are, to some 

17— P. 



256 PELLAGRA 

degree, tainted by the poison of pellagra. In the 
hospital of Kasr el Ainy at Cairo, in ten years more 
than a thousand pellagrins have been treated. Each 
year, out of this number, forty cases complicated 
with mental disease are successively turned over to 
the asylum of Abbassia, where the writer has been 
able to study them. 

Outside of the hospitals, the study of pellagra 
among the population of the country districts has 
been undertaken by Sandwith (Egyptian Congress, 
p. 485). He makes an average estimate that more 
than 36 per cent, of the Egyptian peasants are 
affected. In the less wretched districts the propor- 
tion may fall as low as 15 per cent., but elsewhere 
rises to over 62 per cent. 

In lower Egypt the average would be greater, 
even in young women. The considerable rate of 
still births would not be properly explained without 
reference to this scourge. 

In upper Egypt the greater dryness and the use 
of millet as food diminishes the danger; and prob- 
ably also, the countries further removed from the 
seacoast consume less imported corn, which is the 
more dangerous because of spoiling during trans- 
portation. 

The number of pellagrous insane is continually on 
the increase; and yet only those are counted who 
show the definite physical stigmata, such as those 
whose photographs were presented to the Academy 
of Medicine in 1907, for the hereditary pellagrins 
do not always show these stigmata so definitely. 



PSYCHIC AND PARETIC PHENOMENA 25 T 

The erythema varies in appearance according to 
the stage under consideration, though the location 
may be the same. 

Eacial characteristics are manifest in relative 
peculiarities of pigmentation; it is thus that old 
scars, instead of presenting a dark color, as in case 
of the white man, show, on the contrary, more of a 
gray tint in the Arabs, in consequence of the scaly 
thickness of the dry and hypertrophied skin. 

The climate and the Arab costume produce also 
certain local peculiaritites of this erythema; thus 
the short and large sleeves cause the pellagra gaunt- 
let to be more extended; the gandoura, freely open 
at the breast, cause the dermatitis to extend to the 
neck and sternal region. (See Frontispiece.) On 
the legs the boot erythema can extend often above the 
knee and the bare foot is involved, as is the hand. 
One can observe either increase of pigmentation at 
the beginning, or the final depigmentation with a 
dystrophic state of the epidermis which becomes 
like parchment, dried and scaly. Scars of old ulcer- 
ations frequently occur in these people and make 
further changes in the aspect of the skin on the most 
exposed parts. 

The ulcerous stage is sometimes preceded by a 
phase of desquamation which occurs in strips of pig- 
mented epidermis leaving cracks and fissures. We 
have made various photographs of these different 
phases. In the negro the erythema, especially on 
the face, may take the appearance of pigmented 
grains of millet, apparent on the brow, the neck, the 
cheeks and around the lips. 



258 PELLAGRA 

It is unnecessary further to discuss either the 
well-known skin lesions with their seasonal recur- 
rences or the prominent visceral troubles which 
accompany them (diverse gastro-intestinal troubles, 
gastralgia, diarrhea, etc.). We will restrict our- 
selves to the mental and nervous peculiarities, whose 
manifestations are generally consecutive to the pre- 
ceding symptoms, although they may precede or 
even replace them entirely. 

The mental state of these patients generally is 
characterized, after the initial stage of feebleness 
and irritability, by an apathy with physical and 
mental depression and diverse phobias. Sitophobia 
is frequent and coincides with the gastro-intestinal 
troubles, gastralgia, cramps, nausea, seborrheal con- 
dition, constipation and diarrhea. 

Mutism is usually associated with sitophobia; the 
patients become excited and frightened, seclude 
themselves and seek dark corners (photophobia, 
hyperthermia, painful, cutaneous paresthesias). 

Mental stupor is accompanied by amnesia and by 
spasms, including vertigo and epileptic convulsions, 
or their psychic equivalents. In the first rank of the 
latter phenomena must be noted ambulatory auto- 
matism, a frequent cause of unconscious suicide by 
precipitation into, or drowning in the canals of the 
Nile. 

Autoaccusations or nosophobic, hypochondriac 
preoccupations are not rare, being associated with 
vague ideas of persecution. Stupor is interrupted 
by automatic raptus and various spells with or with- 
out confused dreamy states. 



PSYCHIC AXD PARETIC PHENOMENA 259 

Sitophobia may be due to dysphagia and anor- 
exia, and the apathy may be confined to katatonia. 
It yields sometimes to sitomania at a later phase, for 
pellagrous insanity frequently assumes the chronic 
form with or without intermissions. That is easily 
understood, for convalescent patients returning to a 
dietary of spoiled corn, the same causes then repro- 
duce their same effects. Relapses are frequent, and 
the chronic states also: complications, furthermore, 
through other etiological factors of psychosis are not 
rare. 

In Egypt the pellagrous intoxication at times 
occurs with hashish intoxication. Then there is the 
possible combination of various infections, especially 
of malaria and of syphilis, and such endemic para- 
sitism as ankylostomiasis, which is found very prev- 
alent among Egyptian insane as well as among the 
native population in general. 

With regard to syphilis, attention has already 
been called to the frequent occurrence of general 
paralysis among the Egyptian Arabs. The question 
is, does pellagrous pseudo-general-paralysis exist 
among them, or is this a simple specific general 
paralysis modified by the pellagrous intoxication? 
The question is not a new one, and it was raised by 
the French school at the time when the academic 
debates started by Baillarger in 184-7, 1 were attract- 
ing attention. 

1 T"ne point was with regard to addressing a programme of in- 
quiry, proposed by Roussel, to the Minister of Commerce — an 
inquiry to be made in Spain as to the causes and manifestations 
of pellagra, which was then wide-spread in the southwest of 
France. 

M. Gibert, member of the Academy, expressed an opinion con- 



260 



PELLAGRA 



An examination of the pellagrous lunatics among 
the Arabs at the asylum in Abbassia show that true 
pellagra is very frequent among them, as it is among 
the population from which they come. In addition 
to the insane who have become pellagrous, there are 
cases of insanity consecutive to pellagra and in strict 
causal relation therewith. Such cases show their 
pellagrous origin by typical phenomena united with 
characteristic physical stigmata. 

A certain number of paralytic insanities coincide 
with pellagra in their essential phenomena, and con- 
firm the opinion of Baillarger that the ultimate 
paralytic stage of pellagra may represent a condi- 
tion identical with paresis both clinically and path- 
ologically. These cases do not weaken in any respect 
the character of specific general paralysis, from 
which they are distinct, and which is, of course, 
ascribed to syphilis. The two forms, however, may 
be associated, that is, one may observe Arabs suffer- 
ing from general paralysis who are at the same time 
syphilitic and pellagrous. 



trary to the corn theory, resting for support on the cases observed 
by him at Paris in the Hospital Saint Louis. 

He probably had before him hereditary pellagra, analogous to 
the case mentioned by Regis of a patient that had never eaten 
spoiled corn, nor even good corn, but was the daughter and grand- 
daughter or niece of confirmed alienated pellagrins. 



CHAPTER VIII 

Pathological Anatomy. 

The researches of Babes, Sion and Marinesco, as 
well as those of the Italian investigators Rossi, 
Righetti, Grimaldi, made by the method of Nissl, 
have shown that there occurs in pellagra consider- 
able cellular change. Parhon and Papinian noted 
(1905) in a case of pellagra, alterations of the neuro- 
fibrils predominating in the large cells. The giant 
cells show a red-mahogany coloration of their cyto- 
plasm and a complete absence of neurofibrils. The 
nucleus is, according to the stage of the process, 
vesicular, atrophied or invisible. The nucleolus 
takes a stain with difficulty in the most altered ceils. 
The appearance of the large cells of the anterior 
horn resemble very much the giant cells of the 
Rolandic area (Regis). 

The pathological changes seen in 113 autopsies, 
seventy of which were done by Lombroso and his 
students, in their essential details, are given in the 
pages which follow. 

Meninges and Brain. — Milky opacity of the pia 
mater and thickening of the pia mater and arach- 
noid, often circumscribed, more frequently diffuse, 
were found thirty-three times; four times with a 
purulent exudate ; five times with hemorrhagic extra- 
vasations under the arachnoid; twenty-four times 
extensive or partial edema of the brain, sometimes 
with edematous softening around the pillars of the 
fornix or at the foot of the hippocampus; five 



262 PELLAGRA 

times hardening of the cerebellum was seen; on the 
other hand, in 8 cases it was found soft and edema- 
tous ; eleven times atrophy of the brain, especially in 
the cortical substance. The weight of the brain was 
found diminished in 18 out of 28 cases examined, 
while in 7 cases it was increased above normal; 
twice it was found hardened; five times hyperemia 
of the brain was noted, twice of the corpus striatum, 
in one of which cases it was more marked on the 
right side than the left ; four times, on the contrary, 
there was seen anemia of the brain. 

Other observers have likewise noted similar 
changes. Nardi, Fanzago and Strambio report 
injection of the membranes, with thickening of the 
arachnoid and congestion of the sinuses. In almost 
all of his autopsies, Liberali found inflammatory 
changes in the arachnoid. In 21 out of 41 cases 
Verga found adhesions of the dura mater to the 
superior cranial bones ; twice thickening of the dura 
mater; three times opacities of the arachnoid; and 
once only adhesions of the pia mater. 

In 16 autopsies Rizzi found the pia mater always 
involved. Morelli often found extravasations of 
blood under the meninges. Verga found in eight 
cases hydrops of the ventricles, and in four soft- 
ening of the cerebral substance. 

Microscopic examination showed 11 times fatty or 
pigmentary degenerations, 4 times both combined, 
in the walls of the cerebral capillaries, three times 
with calcareous degeneration; once sclerotic changes 
in the brain ; once dilatation of the brain capillaries. 
In twelve examinations of the sympathetic ganglia 




Plate XVI. South Carolina case. "Wet" dermatitis of hands, face and 
lips. Note characteristic facial expression. Courtesy of Dr. J. J. 
Watson. 



PATHOLOGICAL ANATOMY 263 

marked pigmentation of the ganglionic cells was 
found eight times. 

Spinal Meninges. — Still more important were the 
alterations of the meninges found by Lombroso, 
Tonnini and Belmondo in 71 autopsies. 

Tonnini found hemorrhage under the arachnoid 
4 times in 51 cases, of which two cases were scor- 
butic ; in other cases no hemorrhage was found, but a 
decided circumscribed pigmentation in certain parts 
of the spinal meninges. Anemia of the membranes 
was found in 8 cases out of 51 with concomitant 
anemia of the spinal cord also. 

Hyperemia of the membranes was found 17 times, 
the arteries and veins being tortuous, and the in- 
ternal face of the dura mater sometimes mottled by 
dark red spots. In these cases the cerebrospinal fluid 
was increased as well as turbid and reddish in color. 
In 31 out of 71 autopsies Tonnini and Belmondo 
found, besides the thickening of the membranes, 
osteomata (ossifying arachnoiditis) in addition to 
senile alterations. Out of 14 autopsies Tamburini 
found osteomata in 9 cases where the age exceeded 
50 years, but all were paralytics. 

Spinal Cord. — Omitting older writers, Liberali, 
Verga. Labus, Xardi, Marce, Billod, Brunetti and 
Bouchard, have studied the spinal lesions in pel- 
lagra. 

In an examination of the two halves of the gray 
axis Tonnini found in six out of fifty-one cases, 
granular and pigmentary degenerations with cellular 
atrophy. He observed changes in the left dorsal seg- 
ments in one individual who had muscular atrophy 



264 PELLAGRA 

of the thorax and the inferior extremities. The 
amyotrophy was on the left side while on the right 
there were signs of anterior poliomyelitis. In this 
case, microscopically, there were observed cellular 
atrophy in the anterior horn of the left side, granu- 
locellular degeneration on the right and incipient 
degenerations in both lateral columns. 

In twenty-two out of fifty-three cases he found 
softening of the cord in the dorsal region ; in fifteen, 
softening in the cervical region along with similar 
changes in the dorsal and lumbar regions. The cen- 
tral canal may be dilated (Syringomyelia). Eleven 
times out of fifty cases he found anemia of the cord, 
a condition more marked in the substance of the cord 
than in its membranes. 

Microscopic examination of the cord by Golgi's 
method showed in places many nerve fibres poor in 
myelin, and demonstrated numerous round or oval 
nucleated bodies, thirty to sixty micro, in diameter, 
many of which were surrounded by a fine stroma of 
granular protoplasm with proliferations. 

Tonnini in eight of thirteen cases found marked 
pigmentation of the cells of the anterior and poste- 
rior horns with disappearance or alteration of their 
nuclei. From these and other lesions Tonnini 
thought the microscopic anatomy very similar to 
that found by Tuczek in ergotism. 

Hieronimis noted small-cell infiltration of the 
gray and white substance of the cord, and around 
the ependyma with dilatation of the perivascular 
and pericellular lymph spaces. Marchi noted altera- 
tions in the vessels of the gray matter. 



PATHOLOGICAL ANATOMY 265 

Belmondo, in his very important researches on 
twenty cases, distinguished two kinds of changes, 
the acute and the chronic: The first were noted 
exclusively in cases terminating with so-called 
typhoid pellagra, and consisted in an abundant infil- 
tration by leucocytes of the meninges and of the cord, 
and in a great dilatation of the vessels, which were 
filled with blood; in other words, there existed an 
acute meningo-myelitis. 

The alterations of a chronic nature existed, on the 
other hand, also in cases of severe pellagra in which 
death had been due to an intercurrent malady. 

In all cases he found varying degrees of degener- 
ation of the crossed pyramidal tracts, from slight 
changes with loss of myelin up to an actual sclerosis. 

The posterior columns, those of Goll and Burdach, 
exhibited also degenerative changes. These lesions 
of the posterior cord resembled in many cases those 
of incipient tabes, but in the pellagrous the posterior 
columns were more involved in the superior dorsal 
and cervical regions. 

Other less important changes were noted occasion- 
ally in the white substance of the cord; as well as 
certain alterations in the ganglionic cells, which 
were frequently atrophic and, even in the youngest 
cells, filled with pigment. 

This increased pigmentation, found constantly by 
Lombroso in the sympathetic and spinal ganglia, 
is regarded by him as of much importance, being an 
indication of profound nutritional disturbances 
occurring in the central nervous system. 



266 PELLAGRA 

Belmondo, from these researches, concluded that 
severe cases of pellagra are accompanied constantly 
by systemic degenerations of the lateral and pos- 
terior columns of the spinal cord in the form of a 
combined sclerosis. According to Italian authorities, 
combined scleroses are more usual. 

These cord lesions of pellagra, like those of ergot- 
ism, are not indeed essentially progressive in their 
nature; advance in the process is due to renewed 
poisoning by the toxic agent, and often it is only 
with the appearance of other intercurrent morbid 
conditions, especially a cachectic state, that the pro- 
cess shows any advancement; and such progress is 
always slow. 

Since 1894, Pierre Marie has made several investi- 
gations of the alterations of the cord in pellagra; 
and he has undertaken to compare the cord lesions 
of tabes and of pellagra. He says : "Thus it is that 
in pellagra, where there exist most often combined 
lesions of the posterior and lateral columns one can, 
according to Tuczek's recent work, show that the 
degeneration in the posterior columns has a locali- 
ization different from that of tabes. Indeed there 
does not exist in pellagra, contrary to what is found 
in tabes, any lesion either of the posterior roots or 
of their intramedullary prolongations (zone of 
Lissauer and Clarke's column). The degeneration 
of the posterior columns must then be attributed to 
a mechanism other than that of tabes. Indeed while 
the degeneration of the posterior columns in tabes is 
exogenous, that is, arises especially from the lesion 



PATHOLOGICAL ANATOMY 267 

of the posterior roots; that of pellagra — at least in 
typical cases — is endogenous, that is, it takes its 
origin in consequence of the alteration of certain 
cells of the gray matter of the cord known under 
the name of 'cells of the posterior columns.' This 
alteration would be produced by a poliomyelitis 
especially marked in the upper median dorsal region, 
but extending almost all the length of the spinal 
axis. With regard to degeneration in the lateral 
columns, this would be due to this same poliomyelitis 
acting on the 'cells of the lateral columns.' ' ; In all 
probability it is necessary to consider the process in 
the cases of pellagrous myelitis as an intoxication in 
which the vessels of the gray matter play the prin- 
cipal role. 

Dide and Leborgne have described in certain cases 
of non-pellagrous dementia precox, lesions iden- 
tical with those noted by P. Marie in paretic pella- 
grins. They also found them in old epileptics. With 
Dide. the author presented to the Anatomical So- 
ciety spinal cords of patients who died of dementia 
precox with analogous lesions, whereas the spinal 
cords of pellagrins, collected by him, in Italy at 
Tessin, did not present characteristic alterations. It 
appears, therefore, that certain insane pellagrins 
present cord lesions relatively independent of pella- 
gra, which arise from secondary auto-intoxications, 
not characteristic of their pellagrous intoxication. 

Duse 1 found in a great number of pellagrins a 
marked frequency of the Babinski reflex. Galesesco 

J Archiv. di Psychiatria, January, 1904. 



268 PELLAGRA 

and Slatineano, 1 of Bucharest, have made examina- 
tions of the cerebro-spinal fluid with practically 
negative results, but when this is from cases of 
paretic pellagra or general paralysis associated with 
pellagra, one may conceive the possibility of a diag- 
nostic change in the albumen of the spinal fluid, and 
of an increased number of lymphocytes due to a 
concomitant general paralysis. 

Lungs. — The frequency of edema, pleurisy, hyper- 
emia, emphysema, and pneumonia in the autopsies 
on pellagra in Lombardy is established ; tuberculosis, 
however, seems rare there. Still at Trent in fifteen 
autopsies nine cases of tuberculosis were found. 

Heart. — The examinations of the heart showed 
twelve times hypertrophy, sixteen times atrophy 
(Barum, Verga), thirty-three times softening of 
the myocardium; seven times hydropericardium ; 
eleven times aortic atheroma. Verga found once 
aneurism of the aorta, and twice hypertrophy of 
the heart. Labus found, in one hundred autopsies, 
fifteen cases of hypertrophy and atrophy of the 
heart in advanced and old pellagrins. With the 
microscope very notable changes were found: most 
frequently brown atrophy of the muscle with cellu- 
lar infiltration (twenty-eight cases in thirty-five) 
or fatty degeneration. 

Liver. — The lesions of the liver are very common ; 
it is sometimes small, again enlarged and friable, 
and brown atrophy occurs. Verga noted cirrhoses 
and Chiarugi found in twenty-nine autopsies, nine 
fatty livers. The weight of the liver is often sensi- 

iSocietS de Biologie, 2 Aout, 1907. 



PATHOLOGICAL ANATOMY 269 

bly diminished, sometimes by half; fatty infiltra- 
tion also is found and congestion or granulo- fatty 
degeneration. 

Spleen. — The spleen is also frequently atrophied, 
forty-one times to twelve hypertrophies. Labus 
and Verga likewise reported atrophy of the spleen 
even in cases of typhoid pellagra. 

Kidneys. — These are often fatty, atrophied, cir- 
rhotic or cystic (once uric acid calculus). Very 
rarely they appear normal. In forty out of fifty- 
two cases the weight of the kidneys was found 
diminished; almost always renal sclerosis is asym- 
metrical. Gianelli notes the frequency of Bright's 
disease in pellagra, and fatty degeneration of the 
epithelium of the tubules is observed with or with- 
out interstitial sclerosis (Festler). 

Vassale and Belmondo have described in cases of 
pellagra a form of chronic nephritis with fatty 
degeneration and desquamation of the epithelium of 
the tubules. 

Intestines. — For many years muscular atrophy 
has been described; also hyperemia and ulceration 
of the rectum, to which too much importance has 
been accorded. Rarely anemia or hyperemia of the 
gastric and intestinal mucosa have been noted (twice 
in seventy autopsies), as well as chronic enteritis 
with or without cicatricial constriction, thickening 
of Peyer's patches and cystic degeneration of the 
sub-mucuous glands. 

The examination of the suprarenal capsules, of 
the pancreas and of the testicles offered nothing 
notable. 



270 PELLAGRA 

The female sexual organs, however, showed 
various alterations, hyperemias, polyps, tumors, 
fibromata of the uterus, calcarious bodies in the 
ovaries, etc., etc. 

Muscular System. — In forty-four cases the mus- 
cular system was found atrophied twenty-one times ; 
normal or well developed twenty times; athletic 
once ; affected with fatty degeneration twice. 

Skeleton. — Fragility of the ribs was met with in 
eighteen cases out of forty-two. These persons 
weighed from forty-nine to fifty-three kilograms, 
were not of an advanced age, and had, in part, 
craniums more solid and heavier than normal. In a 
single one of the cases the cranium was also fragile ; 
in eleven the bones of the skull were thin. 

Fragility of the bones was long ago observed, but 
without special importance being attached to it 
(Bouchard, Orsolato, Villergois, Strambio, the 
elder). This fragility depends on the eccentric 
atrophy of the compact substance with hypertrophy 
of the medullary substance, which the microscope 
demonstrates. 

In the tubular bones, as in the spleen, numerous 
cells were found, in which were included red cor- 
puscles, one part of which was well preserved, and 
the other part transformed into granular pigment. 

Skin. — Grimni has made a comparative study of 
the alterations of the skin in pellagra with the skin 
of healthy subjects, young and old. He found 
marked atrophy of the stratum corneum, copious 
desquamation, active reproduction in the Mal- 
pighian reticulum and marked sclerosis of the ves- 
sels of the papillary layer and the derma. 



PATHOLOGICAL ANATOMY 271 

Lombroso thus sums up the pathology of pel- 
lagra : 

There are found irritations, exudations and hyper- 
emias localized more commonly in the membranes 
of the brain, spleen, liver, kidneys, inferior portions 
of the intestines and above all in the spinal cord and 
its coverings. 

Atrophy of many organs occurs; especially those 
innervated by the pneumogastric : heart, kidneys, 
spleen, liver, intestines and lungs { besides these, the 
ribs and the muscles. Brown atrophy of the heart 
with cellular infiltration and diminution of weight 
was found frequently in the absence of general 
marasmus and this, with other visceral atrophies, is 
common even in well nourished individuals. Fra- 
gility of the bones is ordinarily confined to the ribs. 
Fatty degeneration of the muscles is infrequent and 
then usually confined to certain muscle groups. 

Fatty degenerations are common, and such changes 
are observed in the kidneys, liver and at times in the 
heart; and, what is of more import, in the spinal and 
cerebral vessels. 

Very characteristic of pellagra is the great fre- 
quency of pigmentary degenerations. 

Thus, as noted, one finds brown atrophy of the 
heart, which is an atrophy with pigmentation; pig- 
mentation of the liver cells and sometimes pigmen- 
tation of the cerebral vessels and of the spinal and 
ganglionic cells, with or without fatty degenera- 
tion. In one case was seen a general pigmentation 
of the kidneys, the heart, the liver, and the vessels 
of the brain (hemolytic cellular disintegration). 

18— p. 



m® 



Y MOT A V&El&A$$& JOHTA^l 



degeneration, as calcareous degeneration Q&T^h£ 
cej^i^tires^^ 

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$<* le&f^ai&ffeej ^^ifist$©uW£&f89 dmW8&WdP*£ 

With. .8^flil9TOO gJi 

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^SagiMM&it^^^ 

,&dh 9iii o^ b9fiftrioo yliiBnibio si 89fiod 9ffJ io tj1I1§ 

muscular tissues, fragilitas ossium, j^en^rjai^i^^ 
atrophy with a sj^]$ ; .^^ 

■«S^!r<f ifeffllSlraoJ'b!^ s?£f*> : w^rfi^m^HkiftP 
rftc/^^^f^y^^^EaflAs^g^^^ &£> ftp W 

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.1—81 



PATHOLOGICAL ANATOMY 
AflOAJLiaSL 



Darts 

-ror*i9J? 

way 

comm 



commonly touna, especially m tne ganglionic £ens 
the muscles orrhe heart. 4he h&patLc cells and m, the 

sifiTis. r T]ie hyperemic and 



uyperemic ana. anemic com 
tne^edemarVor tlie central hefVous system, {noug{i 
frequently,- present, are by no means the char- 
actejistic changes, neither are those mnahimatory 

O. jfoOl 'lOtfSTAtf 9HT lo. nQntTI9fl9>>9CT _ .g^91IL 

conditions such as pacnymenms^tis and cerebral and 

pi 

-m 

9TT9T1 9fiJ 

.worthy and c6nstant lesion, and . one r that may be 

e^ially or its lateral columns. 



columns; in tne former the Dvra'mickl tracts ate 




generally 

•te&M'tfblWmifiP istgh<ft»nf'»ib*>fj)fol«in*ti!tljir(ia ]the 
.§riiJnBw isx 8B a™ S9lul8 faslinU art") ni jrrgfslteq lo 



274 PELLAGRA 

dorsal regions of the cord, while that of the posterior 
columns is limited to, or rather most distinctly 
marked in, the cervical and dorsal regions. 

"Microscopically, the affection seems to be a pri- 
mary degeneration of the nerve fibres, with sec- 
ondary proliferation of the neuroglia, the walls of 
the vessels not being necessarily implicated; some- 
times granular cells, and more frequently amylace- 
ous corpuscles, are met with in the degenerated 
areas. Degeneration of the anterior root fibres 
along the anterior cornua has also been demon- 
strated, while there is to be found in addition a 
more or less considerable degree of pigment atrophy 
of the ganglion cells in the anterior cornua, with 
sclerosis of the matrix and atrophy of the nerve 
roots. Besides the excessive pigmentary deposit 
found in the peripheral ganglia, both spinal and 
sympathetic, there are no characteristic microscop- 
ical evidences in other parts of the nervous system. 

"Typhus pellagrosus furnishes us with definite 
post mortem results — chronic gastro-enteritis with 
formation of ulcers and swelling of the mesenteric 
glands, and well marked changes in the central 
nervous system, associated with secondary affection 
of the kidneys, lungs, pleurae, etc., being the main 
features on examination. It is to be noted that the 
spleen is usually involved in the general visceral 
atrophy, and is never enlarged." 

He draws a strong analogy between pellagra and 
ergotism both etiologically and pathologically. 

[Complete and detailed reports on the pathology 
of pellagra in the United States are as yet wanting. 



PATHOLOGICAL ANATOMY 275 

It has, however, been shown by several writers that 
the pathology of the disease, in a general way, shows 
no essential deviation from Italian pellagra. The 
most detailed report has been made by Harris, who 
has confirmed, in their usual features, the customary 
skin and visceral changes. With regard to the cen- 
tral nervous system he has found in the brain the 
alterations described by Babes and Sion and con- 
firmed by Marinesco and others. These are in the 
nerve cells, especially in the large chromophilic 
cells of the cortex, the presence of unmistakable 
degenerative changes. The tigroid bodies fail to 
stain with basic dyes, and the cell becomes swollen 
and vacuolated. The nuclei are frequently pushed 
to one side, show swollen nucleoli and will not take 
basic stains, the pigment is also scattered through- 
out the cell body. The processes of the cells often 
appear broken and seem swollen. The pericellular, 
lymph spaces are dilated, and the walls of these 
cavities often lined with yellow pigment. In the 
brain tissue, small collections of lymphoid cells are 
frequently encountered, and the neuroglia cells in 
the vicinity of the blood vessels are swollen. Harris 
further states:* 

"In addition to the changes mentioned, I would 
remark that in all of my cases the small vessels of 
the brain seemed unusually filled with blood, and 
the perivascular lymph spaces were quite uniformly 
dilated. There were no collections of lymphoid cells 
anywhere in the tissue. The nerve cells showing 
degenerative changes usually measured less than the 
normal ones, and always contained a greater or less 

•Trans. Nat'l. Pellag. Conference 1909, p. 01. 



m 



TMOTA^jftMBBpJOHTA'I 




fiaMM^ypI,^^ ffi£ to«?-Mfl^ 9 &f Js ffig 



lteS|by;,_ 
9 <Kr#°life?fe^a1?nf^ 9 ^ffie 1 ^Pfl8afi^a¥ , ll 

So far as I am, aware, no one has previ(f3s^?ol^fWa 
nifiiflOD bvawIb bfifi .gsno Ibotioxi 



p4 feHbi^rif^m^pa^^ 
r J gf™op%^;>»<* 9 alfy 8 i^a§9 



m^wmfm^mim 



.16 .q ,eoei 99fl9i9lnoO .ssll9*l A'tBVL .aaBiT* 



PATHOLOGICAL ANATOMY 277 

He also says: "^fflam&Hsaits of the work of 
Bietti, it is not improbable that circulatory changes 

' .TXaitTACJflT CTttA, atXAJJHaOH*! JlI80K00fflj8I80Ki>&a 

are frequent in the central nervous systenl in pella- 
gra as heohffs»^ho^nitha^ifequitea^<p^piirtiQirof 
£te$ase&lhl<retifliaLis;3^^ $$m 

fteeeent£g€r; fcheioppctedteislate o£ hypferQidiatQeouiesj*'^ 
doid77 ai nommoofljj Jon ai& 89389 iud r TiIuofftib on 
-luO Jdnob riojjrii ni bavioyni nsiio si aiaorrgjsib sdd 
bi&^gdi asijiioilJuB emoa doidw .nmsd^i'is 9di io ebiz 
lo aoisdi 9vifonfiaib on gi 9i9fij .oinomongodj^q 8i? 
srij no" bnsqsb janrn aiaoirgcib erfi bus .9a£98ib arii 
.9mtoiq luoinilo srfj lo "awob-fida bnu add^i! 
^ooeiioqini donm lo T9;tfj3m £ 8i aiaongfiib yfr^a 
taBtioqmi Jaom 9dT J : bii^a yftn909i zsd humusO 
orgofoT§jsIl9q gnJ gniyqnooo vron nreldoiq isoibgnx 
vhfi9 ns §nirfaild£-i89 lo iudl f idnob tuodiiw t ai bisa 
io ta9iiJ3 oj gldiaaoqmi ai ii f siil* JnodtiW .aiaorrgeib 
dbidw fiT§Bll9q lo aJo9na IijimxBd 9ffi 9ij3ioil9m.B 
b rfoua p 98ijjoo lo .bnA ".9ld.eJiv9fli yjkjisl ni998 
bns aldnob ni b9vIovai Tlin9np9ii ooi Ub ai aiaongsib 
teifin aiaongBib adJ r 9arijoo lo .aamb 7flfiM .aahrlnoinib 
-b-ioooc mi29d JnamijmJ bns : 9inlun 9viifiJn9l n lo ed 
977 .b9m9onoD ai 9iuioiq Icoinilo 9f[j an ijj! 08 .^f§ni 
arh lo vioteid 9dl noitnrabianoo ocrni 9?!^ yum 
b9889iq9b s lo vllnijsn f 89onjsd-iui8J[b Iftjnarn blim 
-qaqavb ar, dot/a ,a90flBdiirtaib Inn b89Jni-oi Jang ;aq7i 
[oo io cadrieib ? teiidi .9.)iJ9qqxj ni 9§ufido f /jia 
:•-/ ;9dof;br>9f{ diiw fiinmoani bun vgiHev ;noiigq 
-fidqos9 fdiuom adJ ni gnixnjjd ae dona ,ania9d:r39'ij3q 
-fioionoi .teai ba* sbazd 9rft no to f dofiraoia ban zirg 
sdl ni safgnBth :.ola .ybod sdt brinom sbned f noii 



.BiolBlaaBiT odl <t<j gl i9tqBdD glrlT* 



CHAPTER IX 

DIAGNOSIS, PROGNOSIS, PROPHYLAXIS AND TREATMENT.* 

The diagnosis of pellagra in pronounced cases — 
with the so-called pellagrous triad of cutaneous, 
gastro-intestinal and nervous phenomena — presents 
no difficulty, but cases are not uncommon in which 
the diagnosis is often involved in much doubt. Out- 
side of the erythema, which some authorities regard 
as pathognomonic, there is no distinctive lesion of 
the disease, and the diagnosis must depend "on the 
lights and shadows" of the clinical picture. 

Early diagnosis is a matter of much importance. 
Camurri has recently said: "The most important 
medical problem now occupying the pellagrologic 
field is, without doubt, that of establishing an early 
diagnosis. Without this, it is impossible to arrest or 
ameliorate the harmful effects of pellagra which 
seem fatally inevitable." And, of course, such a 
diagnosis is all too frequently involved in doubts and 
difficulties. Many times, of course, the diagnosis must 
be of a tentative nature, and treatment begun accord- 
ingly. So far as the clinical picture is concerned, we 
may take into consideration the history of the case; 
mild mental disturbances, usually of a depressed 
type; gastro-intestinal disturbances, such as dyspep- 
sia, change in appetite, thirst, diarrhea or consti- 
pation ; vertigo and insomnia with headache ; various 
paresthesias, such as burning in the mouth, esopha- 
gus and stomach, or on the hands and feet, formica- 
tion, bands around the body, etc.; changes in the 

*This Chapter is by the Translators. 




Plate XVII. South Carolina case. Same as Plate XVI. Conva- 
lescenl and showing pigmentation of hands and arms. Courtesy of 
Dr. J. J. Watson. 



DIAGNOSIS 279 

knee jerks, with usual exaggeration; pupillary phe- 
nomena, especially of a unilateral character; general 
malaise with muscular weakness, especially in the 
lower extremities ; possible tender spinal points ; per- 
haps loss in weight with a generally lowered physi- 
cal, nervous and mental vigor. A tentative diagno- 
sis made on such grounds must frequently await the 
appearance of more conclusive symptoms, especially 
the erythema. 

The importance of this early diagnosis has led to 
a search for some positive laboratory method for 
recognizing the disease at an early stage, and there 
is not an inconsiderable literature on certain blood 
serum reactions, thought to be of importance in this 
connection. These methods include the toxicity of 
pellagrous serum as tested on animals, and the 
appearance of a "maize-precipitine" in the blood 
of pellagrins. Camurri in a recent discussion of this 
subject, with a review of his own experimental work, 
states that the toxicity of pellagrous serum is incon- 
stant, and hence not to be depended upon for 
diagnosis. The "precipitine" test, in a general way, 
is made by adding a small quantity of the sus- 
pected serum to a standard infusion of corn; the 
mixture is placed at 37 degrees C. for a few hours, 
and if positive, a precipitate makes its appearance. 
With regard to the specificity of such a reaction, and 
its value in diagnosis, Camurri thinks that its only 
value is to show that the individual is an eater of 
corn, and that there has been, within a short period, 
some lesion of the gastro-intestinal tract. From 
other experimental work, he deems the urine of early 



280 



l^blpa%£©T^^aM^ ti<pej 

ranjpcia acoJtstiaaat &et,i6^<bw!toniaffinMy fa$pe®ei4i£$ 
wiAfrihrcreai^BJaMid^^^ 

^i^e^q^th^wds^ad^.^viauioaoo 910m lo eonfnfisqqfi 
These methods, in their present stat^r^lojjn^l a$t 
pzi&ltefA&'min^fhjjmkL&id&i^ «^f ®hi^ Jo^&flr of 
^ufeptheyiaEeiiitowotM oot|>1©^ i^g^nej^lffts^^n^ 
aitt^t fjemai^r^triGtedit© the3lafeafa%3fy*2fiisin^oo8i 
boNdtuazaMpo inquiry ism 3ihsd&E'E$m¥$Mg i£kej £^ 
lemons ^Boiiitthe^riivyuBfi® M^m^^a<^h^.d^!^f^m 
fontv iiDfre^u^Atlyb la&kesg^H^here&iHC dise^^ee/jn^y 
tofc rfecaa^nizexisinssitkoutbsQkim 3»aMfe^ti#?^j($^ 

afMheo ao)eg>Buffibkn^09!f oir ntteur^^niiiftitei^feqtfee 

loBveritiqpr ofttriasoaqdf Mer&itftati tb§/^nb$S3np|€js#s 
ad©irelsufce§f©ina f (fegn@si3^cfarf4haif{ , ©ie .etti«a^e©ij£ 
tek)BslJDfi(peftagrairpoi§em3the jsa^wafofe &&£&&& 
sio&is raised dhangteoiLnsc^ 

.irarijGella9mithiK>res^ei^Tg9#a^Mi^^G^^ disjQa^efr 
.R©iis8ei^?jpBasse€blgmvetj^©j|bfe"i^ to jim^tm^^c^ifd 

^Boha^E^eH^ncdHsi'i'ceBtaiji f ^m^§d^jiitffpl^r tk£ 
imlgBlaferuee ^to^^i&ifieo/^Sfe^^ori^her^i §etos 
floicbtj tort© flthefljaxiate3aaj& ao£ ^9j&Hagra5fMifitoifc 
iskMI mtosffeslMiolJsjrato^em^ satag&o afci^fciieetffe- 
lo@ertaaal|j gsud£> ad ^iagwoM^nanayscf)^ teiide 



DIAGNOS^iW^iROGNOSIS §§? 

^ c For nl# u^lr^^re ^ feffitel &fe& ID18 Hft 

^£fno§iiWpm|rffha3 J ^ 

and it ffli-q^&apeSifJa^u^ f&iSf AHim^ 

ognize pellagra in tooton^Mn^ftn M'to&M 
•W^^^r^erMic^^^e siflai 8 lfc Sfcfe tftWakce 




^tfien^^^fWni^rf^f^mi 
(fe&f^ n a^ck^i"^ 

^^^^ s ^|nfi8ni srtl ^nomfi gnh-mooo nsrlw vlli3io9qsa 

**TO WsOSffer^tM MgnMis ^an^ffiftSns^- 
mand some consideration. In thSFffifS; 7^6^3tfifl% 

"^etlWogite'feid^ WrHSMaY tffip&V jSfiffie^iffifflffiP- 

rye, lathyrism from chick peas and acrodynfa 1 ? 9 ^^?- 

"Wife ^mo^tf 1 aWga^ifffi^^ 

serve to differentiate it. Lathyrism is lackrn§4ff%?an 

'iWMfftftafiinSf^^BHHaai MflHdff^atfa^ ^ 

^ffys^mra^Mic^^ 

Wf ef ella^S Wt^k^ifkmdf. ]0 If & afrer^m& 

-ffiUa^f; tte "«&*'6g$> <* '^hiffl wiwffiri^fHihiPi 

te^tnt^^b^'s^iilat ^°e¥feotesm a^ n ^lll^r i9 lt 

l^l&n^oWfVe^ 1 ^ 

Persia, Alg^'^W-^kfcB, 1 j AW£v£ i#BrJIff(M; 



I'l 



282 PELLAGRA 

form. There are gastro-intestinal symptoms, hyper- 
esthesias, anesthesias, edemas, and an erythema, 
principally confined to hands and feet. Spastic 
phenomena sometimes occur. The course is afebrile 
and recovery is the rule. Fatalities are rare. 

Scurvy, leprosy and beri-beri are often mentioned 
but should be easily recognized. 

Various skin lesions, such as solar erythema, 
lichen, eczema and erythema multiforme may be im- 
portant. Erythema multiforme may at times be a 
real cause of confusion. Its recognition must de- 
pend on its characteristic cutaneous lesions, the 
course of the disease and the general symptomatol- 
ogy. A solar erythema may for a time cause doubt, 
especially when occurring among the insane. Lichen 
and eczema must be excluded on local appearances 
and general course. 

Functional neuroses, especially neurasthenic phe- 
nomena, may for a time remain in doubt, but they 
are usually cleared up by the appearance of the 
erythema. 

Sprue is said to occur in the United States and 
may cause confusion; the course of the disease and 
the absence of skin manifestations must suffice for 
diagnosis. 

Typhoid pellagra may be mistaken for an acute 
infectious disease or uremia or diabetic coma. The 
history of the case under such circumstances may 
be of much importance. The character of the tem- 
perature, condition of internal organs and general 
symptomatology should usually serve for differen- 
tiation after a short time of observation. 



PROGNOSIS 283 

PROGNOSIS. 

There are two factors, with regard to pellagra in 
the United States, which should not be overlooked 
in dealing with prognosis. These are, first our com- 
paratively brief experience with the disease; and, 
second, the fact that even this experience is based 
very largely on the treatment of asylum cases, 
admittedly the most hopeless type of the disease. 
It is manifestly unfair to expect improvement from 
any treatment when it is applied to cases not only 
far advanced, but likewise victims perhaps of many 
serious secondary organic changes. 

Nevertheless, even when these factors are given 
due consideration, it may undoubtedly be safely said 
that in this country all physicians who have treated 
this disease regard the outlook in individual cases 
as one of great gravity with respect to complete and 
final recovery. The statistics in existence, all based 
on asylum cases and only a small number at that, 
will give a case mortality of from 35 per cent, to 65 
per cent. Such figures should really not be quoted, 
for they certainly give a very erroneous estimate as 
to the gravity of the disease in this country, and 
justify no definite conclusions whatever. In the 
existing state of our knowledge definite information 
is not available, and the opinions of those with 
widest experience must be accepted as our only 
present criterion. This opinion is practically unan- 
imous that the prognosis is grave in all cases. 

Allbutt has said, "When the disease has recurred 
for three or four seasons, and especially if the mind 
be affected, the prognosis is very bad. I gathered 



M ssfMm 

from the physicians Jgf gj^jyjft lunatic asylums that 
recovery of patients once arrived at the asylum 
©iap^I^sMiiy4Wlm*M «fe^nQw;Sffi tft&&lare 

^f&e^F$n^ftr#^§^^^^ 

e&^£e©£©$i&e$A i^iMeS^ai»^%i^itflisI^AteI^ 
fe^p<es§es9V«^^My^^e *m% ^ifeMfy %ifteA#i$ed 
efefi^isxeMmPyfeb ^e^^r©§git &ieno ile-ginl viev 
•aBgejfciiajtt o*> I^lfenses^a^dc^ol^^^er^l^rtkirfiy 
toV^s^gQWtfif^^ %u&Il 



Ife£p Ialf#q^*2^e¥eitlkt9lh^9^er^f eblt#Ha&£ cB& 
mortality, as giveS%P^i^MitMc^|flfel$^§t^^9§i 

^ defei^iitf ffi&^cfeB&ffjft #ilt &a$We1^&We3ot^ 

lMs^im#4a^eSfliJ$te:^ 

^«r^n^i4JM^fe4rid stetal ^4€r4'^^§ne§§?%f6d8Mi 

fe^ot-i%tefimMM?iil^ ^ ^rfn3^-mate§^|coftn(j)8|L 

4Me Iff W^M^eeiteMy^se^ottoitM^ItaiMT^hyS^ 
^a*fe-^te^iWlv^eV"tKl ka^eM?P4h^i&^ie^l%M 
? fea^ ^mM)a I tel)iy^^i^y^iri^fean^m^-J§^ 
Sftet&^h^ E!^mlftBiStiZ'o^se*v^ ^taS^l«h the^lisl- 
IflttseKS^^erfii^ $teQM€#t e^peliten^fl^Wtfee &b 
%ifot Ae tM^^^bm^Mw'^^n M&J^<P$Td$fa8k. 

^f£e<f3^c(kcl^^?le£4fca^ 
T ftoreis^ege' a^qlojfele^! Mm li^^^tflsbfiHr 
=*?#£# A^p%M^%«^ ii e^rfei3Ee -B&b^en teg&fr 
confift^t&^tBe <ffdg&es5 **$$fSg«fi t&e* dft&&l,'<>flfe 
fos^ftm'* c^esssfif^fe^^sfi^fs' rfea^om^l^t^lftfenk 
kfom «*bi* ^^gd^Mo^Se^^^aMQkifOe^Mrtel^e 
b9isjd^B^ I .bsd TT9Y si ?raorrgo'iq ofii ^beiosn-fi sd 



DIAGNOSIS! lA^lT PROGNOSIS §g& 

developsT we L Mlb ppefoablyi^oraegtojla sckajg© £>T$Eptr 
prehensio&J of the jnartMrfiandiJv&DTvaikifealte ift^iJ 
likelihood} cohclud© ^iidfe^d^Qitte^i^^p^lxini^lJ 
basest grave, itiisdby nalnisstD^fho^elesfenoi^iJiis 
There are eevtmn eonsidieraiiiojas O/icmuoJviwi^igfe^ 
i»l^rognosis9 and- arilongftfresBffineiofsfck^ nwrftjinif 
■^drtantis an^eaTly diagnosis vItlm&mKp(B\m»cfwthy 
unanimous; 1 opinion • itEMou^muis^pdM^mlil iterator 
tha<ti early Jeasesjoflfer tke^raaiestjifeAuuns Ieojb tee^fo- 

rrient^ alRj^'oilcourseyJtfee^most^hopeWi prrogno^iis. 

The dEseadeiiiB-^ess^ntialr^ nhEemeiriniitsiithara^^E, 
-but^ ^untoea^e^ y advanees i&*mxsmb&^>mTitih?fhi%U<y 
-mt& tnWfe^Km.\rob0enTEiiti of .ith® IceBiliraJb ftejrnotte 
&?§tem dittle^eanrjjgdiapedyfop- ^roanl^tearbnEdnJ^sJs'iq 
I#4Jo&gi>n©tj;$eBin aiaagmsfcritendra^o stfroeiepfar&liil 
-between : fchis-i disease; andstaiberclftiaf tfcj&Iungs^tafch 
^htfmi^i advancing^ states! q Itobfiv^IMtfe^stfoBOiigh 

rtnrchn misery i ?an[dsisnffering^ oteaKiedi &owIje^KLj;ifc:o 
^ift^ftose^'toviifeaii^ndTtoTooHnsel ftoitiiferQido!^. 
^toiivvaino^a^plyitteotessobi, ailleastrto some^xfeen^, 
=&&h ^r%^ard^lo'peliag5Pa^i /JPfiikgraeds^sidbjectoTfe) 
^tfdSeiT' aeute 'manifestations. and) tHeseCcondititslts 

are of the utmost gravity. The^c^ditdontof typhoid 

pell&grar: i# practically: iropeless^ijQceasioiiallyj ad case 
3-eooverdj irat ^is* ik very/ bare: fFHe txhronic itpe/; #f 
the <ft$ease;-without! r mehtab'invdljvemeinVfiiB^I'aSfiia 

rule;ithe : iM®6tfjhopyfQl l^pepfefepBoiail^df 'jeaarlyotrpfut- 

mont is begrun. >d —9! r w\ r i9fto ? 8nohibnoo 9vft 
Certain symptom s r ax^TOortfeyfiof riiotta withoregard 

to prognosis. As a rule peiiagara r is a/ dilsease of iliistle 
nfeven and [.itriiofakfly ^Bneraily-ae^nowledged'that 
'ffiYetijiiBspediallyA ifl ^hrgW^o^ucofesban^^rmrisiirr^e 



286 PELLAGRA 

regarded as a danger signal. (See p. 214.) The char- 
acter and extent of the erythema, since the time of 
Strambio, has been regarded as no index of the con- 
stitutional disturbance, but we are convinced that 
extensive, moist dermatitis is always accompanied 
by grave general conditions. This opinion has like- 
wise been expressed by Merk in his recent admirable 
study of the skin lesions. Whether such erythemas 
mean some secondary invasion we are not in a posi- 
tion just now to say. Mental involvement always 
adds to the seriousness of the outlook, and such nerv- 
ous disturbances as subsultus, marked tremor, retrac- 
tion of the head, can, as in other affections, be inter- 
preted as an index of severe intoxication. In mental 
cases periods of excitement are not rare and they do 
much to help exhaust the patient. Severe recru- 
descences of the acute phenomena sometimes occur 
during the same season after the patient seemed to 
be on the road to recovery. Steadily progressing 
emaciation, especially if accompanied by an invet- 
erate diarrhea, which is usual, very often ends 
fatally. On the contrary, a tendency to take on fat is 
usually a favorable sign. 

Much of this might be summed up in a general 
way by saying that in advanced cases, with serious 
involvement of the central nervous system, and the 
appearance of what Eoussel calls various consecu- 
tive conditions, offer a far less hopeful prognosis 
than cases of the first or early second stage before 
such events have occurred. 

Certain complications are also of importance in 
prognosis, and should always be kept in mind. By 



PROPHYLAXIS 287 

some malaria is regarded as a very serious compli- 
cation. Then we may have intestinal parasites, such 
as thread worms, round worms, hookworms and 
amebas. Marked nephritis may also occur as well 
as acute bronchitis, pneumonias, decubitus gangrene 
(often difficult to avoid), possibly tubercle, and, of 
course, sudden acute manifestations like typhoid 
pellagra. All these complications may add greatly 
to the gravity of the situation. 

Finally, if the patient is carried safely through 
the acute manifestations of one season, a recrudes- 
cence of them must be watched for during the next 
season, more especially if anything should intervene 
to lower the general resistance, such as acute illness, 
childbirth, etc. Being a chronic disease, pellagra 
demands long, continued oversight and treatment 
much the same as does syphilis. 

It may be added that an hereditary taint may 
prove of much importance in prognosis, as has 
already been pointed out elsewhere. 

Prophylaxis. 

In any discussion of pellagra we must of course 
recognize the paramount importance of prophylaxis. 
The disease is first of all a public health problem; 
and while the treatment of the individual case must 
necessarily appeal to many medical men, yet preven- 
tive measures should, and do, occupy first place. 
Governments have usually displayed much concern 
at the invasion of their territory by this disease, and 
medical men, sanitarians and legislators have joined 
hands in attempts at its limitation or eradication. 

The gravity with which the disease is regarded, 
both in the individual case and in its relation to pub- 

i&-p. 



288 PELLAGRA 

lie health, becomes much more evident when certain 
facts are brought into prominence. Pellagra has al- 
most invariably been found associated with wretch- 
edness and poverty, and the disease has in conse- 
quence been often regarded as an indication of the 
economic conditions obtaining among certain classes 
of people in the country involved ; and thus through 
motives of patriotism or for reasons of policy, or 
even from a sense of shame, publicists have felt 
urged to grapple with the problem. Pellagra, more- 
over, largely involves the laboring classes and so 
menaces the physical integrity of a very important 
part of a nation's population, a part which usually 
forms an essential element of strength and produc- 
tivity. Through its hereditary influences the disease 
also saps the strength of the people in a peculiarly 
hopeless manner, and throws its burden upon coming 
generations, ever spreading wider in its vicious cir- 
cle. Furthermore, the chronic nature of the disease, 
its seasonal recurrences, its too often steady 
advance, with possible years of invalidism and 
not infrequent mental alienation — all result, not 
only in the loss of productive years to the 
nation, but likewise often to the assumption 
of the greater burden of caring for useless mem- 
bers of society, frequently at public expense in a 
public institution, for long periods of time. These, 
in a general way, are the peculiar reasons why pel- 
lagra is regarded as a public health question of no 
small importance ; and why this disease, less import- 
ant numerically than some other well-known, pre- 
ventable diseases, has yet frequently attracted the at- 



PROPHYLAXIS 289 

tention of sanitarians and public health officials, and 
demanded the support of legislators in the enact- 
ment of laws and in the appropriation of money. 

Now, the prophylaxis of any disease must neces- 
sarily depend upon its cause, and with equal neces- 
sity the efficiency of prophylactic measures must be 
in ratio to the definiteness of our knowledge regard- 
ing such cause. The etiological ideas of pellagra 
from a scientific viewpoint are, it may be admitted, 
at least in an unsatisfactory state. Yet, despite this, 
men of the widest experience and the broadest study 
seem convinced that there is some definite etiological 
relation between pellagra and the use of spoiled corn 
as a food stuff. On this assumption they have estab- 
lished extensive prophylactic measures which appar- 
ently in great part have often met with success. 
Under present conditions we must, it would seem, 
try to profit by their example. Of all such work, 
perhaps none deserves more attention or study from 
us than that of the Italians. They have labored long 
and earnestly in this matter, and they are beginning 
to believe that their success is almost assured. 

There is one fact, however, of immense importance 
in the United States which must not be overlooked, 
and which has been commented on by many observ- 
ers, and that is the absence among us, relatively 
speaking, of the poverty-stricken classes among 
which pellagra occurs. It has been said that Ameri- 
cans do not know what poverty is, ana certainly we 
have no such wretchedness and poverty in our coun- 
try as is found in many places in the old world. This 
fact adds a hopeful gleam to an otherwise dark out- 



290 PELLAGRA 

look, and it may not be too much to say that for this 
reason alone pellagra will never secure the hold here 
which it has in other places. But we could hardly sit 
with folded hands depending upon this fact for the 
solution of so serious a matter. We must at least be 
awake to the possibilities which may lie in the ap- 
pearance among us of a disease of such character as 
pellagra. 

As for the methods adopted by the Italians and 
the results, so far of their struggle, no better idea 
could be given than in a brief review of some por- 
tions of the report of Mr. Cutting, elsewhere cited in 
this volume. He personally visited many districts in 
Italy and saw not only the men engaged in the fight 
against pellagra, but was able in many places to 
judge also of local conditions for himself. 

He says: "How shall the people be prevented 
from eating mouldy corn? This is the problem 
which confronts the legislator and philanthropist of 
today. For its clear realization and for the chief 
measures adopted to solve it, we are indebted to the 
Zeist School, and in particular to Lombroso. * * * 
The Zeists have compelled general recognition of 
the obvious truth that prevention is better than cure ; 
and at the same time, by the very dogmatism of their 
monistic creed, have given unity of object to the 
work of prevention." He then reviews Italy's early 
efforts against pellagra, notes the establishment by 
Joseph II of Austria in 1784 of a special hospital for 
the study of the disease at Legnano with Gaetano 
Strambio as director; and the important census of 
pellagrous sufferers made by national authority in 



PROPHYIiAXIS 291 

1879, the consequences of which were renewed inter- 
est in the disease and much activity on the part of 
various provincial governments against its further 
spread. The way was thus finally smoothed for the 
great national law of 1902, under which the present 
apparently successful struggle is being waged 
against this disease. (This law and the regulations 
made under it are given in Appendices I and II.) 

The important dispositions of this act, according 
to Cutting's analysis, are of two kinds, curative and 
preventive; the former include distribution of salt, 
administration of food, either at the patient's homes 
or at sanitary stations (locande sanitarie) , treatment 
of severe cases in hospitals, pellagrous hospitals 
(pellagrosari) and insane asylums. The preventive 
measures include the inspection and testing of all 
corn or meal brought in at the frontiers or seaports 
or offered for sale or brought to the mills; the ex- 
change of good corn for bad; dessicating plants, 
cheap co-operative kitchens; improvement of agri- 
cultural methods ; and the education of the people as 
to the danger of bad corn. In addition, cases of 
pellagra must be reported. 

There are some practical methods authorized by 
the bill and in general use in Italy which deserve a 
brief discussion, since they are in a measure novel 
to us in the United States, and are deemed of much 
importance. 

The free distribution of salt is due to the fact that 
salt is a government monopoly in Italy and its price 
is frequently high. Besides being considered an es- 
sential part of a healthy diet, salt is also by many 



292 PELLAGRA 

considered beneficial to pellagrous sufferers. It is 
stated that the national government in Italy dis- 
tributed over 3,000,000 pounds of salt in this way 
during 1906-07. 

Under the law of 1902 the distribution of a "cura- 
tive diet" is made obligatory, and it is provided that 
such diet shall be distributed for two periods of at 
least forty days each per annum. This diet is ap- 
proved by the provincial Pellagrologic Commission, 
and medicines are also included. 

These provisions are carried out by means of a 
house to house distribution, by economic kitchens, or 
by sanitary stations, all dependent upon the practical 
conditions to be met in various places. 

The economic kitchen is a place where good, plain 
food is supplied to rural populations at a low cost, 
or even gratuitously. Such places are conducted by 
the commune or by charitable organizations or they 
are co-operative. 

The sanitary station (locanda sanitaria) is a de- 
velopment of the economic kitchen in accordance 
with special conditions, and is a place where pel- 
lagrins come once or twice a day, during a stated 
period, to receive food which is consumed at the sta- 
tion. The food consists of soup, bread, meat, wine, 
cheese, milk and vegetables. The general idea is to 
furnish good nutritious, non-maidic food to pel- 
lagrous sufferers during the seasons when pellagra 
is most virulent, spring and fall. Along with the 
diet, in many such stations a course of medical treat- 
ment including hydrotherapy, is given as well. 



PROPHYLAXIS 293 

The value of these stations, according to Cutting, 
is a subject of much discussion. The time of treat- 
ment is too brief, but a large number of sufferers 
are reached, and more than 80 per cent, go away 
distinctly improved, while a large number of incip- 
ient cases, especially among the young, are per- 
manently arrested. For incipient cases it is regarded 
as a valuable curative agent in the fight against pel- 
lagra. In 1907 there were over five hundred of such 
stations in Italy. The best results are obtained 
where the sanitary stations are numerous and are 
kept open for considerable periods of time. 

The pellagrosari are special hospitals for the treat- 
ment of pellagrins. They are intended primarily 
for cases too acute, or too grave, for treatment at 
sanitary stations. The treatment in these institu- 
tions is along the same general lines as elsewhere, 
dietetic, hydrotherapeutic and medicinal. There 
seems a tendency to make use of these institutions 
as a prophylactic measure, admitting thereto prin- 
cipally the young and the incipient cases. 

The insane asylums receive a large number of 
alienated pellagrins, and the tendency is to send as 
many of these unfortunates as possible into the 
asylums, rather than allow them to linger in the 
villages and rural districts. 

The inspection of corn and the prohibition of the 
spoiled grain is conducted by a corps of men acting 
under the sanitary authorities. The distinction 
between sound and spoiled corn is not always easy, 
and several tests are in use. Such tests include the 
general physical characteristics of the grain, dis- 



294 PELLAGRA 

coloration, presence of moulds, loss of lustre, bitter 
taste and peculiar odor. The chemical tests include 
the determination of the proportion of ash, sound 
corn being said not to give more than 4 per cent, of 
ash; Gosio's phenolic reaction, a greenish or purple 
color with ferric chloride ; the reaction of the grain, 
spoiled corn having a higher degree of acidity; the 
germination test, spoiled corn of course losing a cer- 
tain part of its germinating power; and finally the 
use of animals. These tests are not regarded as 
entirely satisfactory, but in practice the sound and 
spoiled grain are said to be differentiated with a 
fair degree of readiness, especially at the frontiers 
and seaports. But meal from home-grown grain, 
at the mills, or on the markets, has given much 
trouble ; and the detection of a spoiled article is said 
to be almost impossible. It has even been urged by 
many that all mills be placed under governmental 
supervision, or be owned and operated by the muni- 
cipalities. 

"Every province of Italy," says Cutting, "has a 
commission for the encouragement of improved 
methods of agriculture." Thus are established the 
Cattedre Ambulanti (moving chairs) or "Farmers' 
Institutes," the activity of which is far-reaching, 
and the influence of which has been notable in the 
progress of agriculture in Italy during the past 
decade. By precept and example these "institutes" 
have taught the peasant how to grow better corn, 
or to replace this crop with some other more profit- 
able one, as potatoes, millet, etc. Cutting thinks it 
no small triumph for these institutions that in many 




Plate XVIII. South Carolina case. "Wet" form. Dermatitis of hands. 
elbows, face and lips. Superficial ulceration of hands. 



PROPHYLAXIS 295 

places they have induced the Italian peasant to 
abandon a traditional crop for one unfamiliar to 
him. The influence of such work is thought to be 
one of the important factors in the restriction of 
pellagra. 

The dessicating plants for the artificial drying of 
corn are of comparatively recent introduction into 
Italy, but are regarded as of the greatest importance 
in the prophylaxis of pellagra. The peasantry not 
infrequently object to the use of the dessicator, 
alleging that during the process the corn loses in 
weight, later it will not germinate and that the cost 
amounts to something. These objections do not all 
hold good, for the loss in weight from the spoiling of 
the grain is also considerable, the best dessicators 
do not impair the germinating power of the grain, 
and the question of cost has been met by a provision 
of the law which allows dessication of corn for 
family consumption at no cost, and the rest at nom- 
inal rates. 

These dessicators are of two types, fixed and port- 
able. The portable are very convenient, but the 
fixed are far more efficient and are preferable. 

Cutting, in describing the Cattaneo type of the 
fixed dessicator, says: "Air heated by a furnace is 
forced by a ventilator into a chamber of seven 
stories. Each story is a circular, revolving tray, 
containing about 1,390 pounds of corn. The top 
tray is filled from above. After a certain time its 
contents are emptied, by pressing a lever, into the 
tray below, in such a way that they are thoroughly 
remixed. The corn thus passes gradually to the 



296 PELLAGRA 

bottom tray, whence it goes to a receptacle where it 
is cooled by means of a ventilator, and thence out 
of the machine by an inclined plane. The first tray 
load of corn takes seven hours to pass through the 
machine; after that 1,400 pounds come out each 
hour. The cost of the machine is about $540, and 
the power required to run it about 2^2 H. P. . . . 
The air is forced through the trays in both an 
upward and a downward direction, and that which 
has absorbed dampness from the corn is replaced 
constantly by dry air; the temperature is kept low 
(about 104° F.), with economy of fuel and without 
risk of injuring the corn. The mechanism is so 
simple that the machine can be handled by any 
laborer of ordinary intelligence." 

There are also good portable dessicators which are 
less elaborate and less costly, but, as stated, far less 
satisfactory. 

The low temperature at which the grain is dried 
does not suffice to kill mould spores, and it is, there- 
fore, considered of much importance not to place 
spoiled corn in the dessicators. Their use is to dry 
good grain for preservation. 

Public dessicators are now numerous in Italy, the 
number in 1907 being given as 461, and the quantity 
of corn dried by them during that year as 54,747,000 
pounds. 

The necessity of properly storing corn, and the 
unhygienic and unsanitary methods in use among 
the peasants for preserving the grain, have been the 
subject of much comment. In recognition of the 
importance of this matter, the law of 1902 provides 



PROPHYLAXIS 297 

for public store houses, but for the present the cost 
of construction and maintenance has been prohib- 
itory. Cutting thinks there is no doubt, however, 
that public store houses will ultimately come into 
general use. 

In the further effort to eliminate from the diet of 
the peasants bread made of corn, there has been 
established another institution known as the rural 
bakery {forno rurale). In this institution good 
wheat bread is furnished at a very low price. In- 
stitutions of this kind are comparatively recent, but 
their number has increased from 77 in 1904 to 591 
in 1907. 

Another effort has been made in the establishment 
of corn exchanges where the peasant may exchange 
spoiled grain for a smaller quantity of good meal, 
some deduction being made for cost of milling, etc. 
The plan is approved by many as a good one, and 
has not proven very costly in comparison with the 
benefit conferred, but it has not been very successful. 

Numerous other expedients of less importance 
have been suggested or even adopted in the struggle 
against pellagra. "In general," says Cutting, "the 
object is to get at the children; to prevent pellagrous 
mothers from nursing their babies, or if this cannot 
be done, to see that the mothers are well fed ; to treat 
a child the moment he or she shows the slightest 
symptoms of pellagra, and to send such children to 
other surroundings." 

Of course while legislative restrictions have their 
importance, yet in this, as indeed in all such strug- 
gles, the education of the people is of paramount im- 



298 PELLAGRA 

portance. The restriction of corn, the change in a 
national taste, the introduction of a varied diet and 
better living conditions, these are the cardinal things 
in such a campaign. "And this is not neglected. 
The indefatigable Permanent Committee of the 
Interprovincial League against Pellagra edit a 
magazine, the Eevista Pellagrologica Italiano^ 
devoted to the struggle against the disease ; popular 
pamphlets are distributed in great numbers; popu- 
lar lectures are held everywhere ; colored lithographs 
representing the healthy laborer fed on sound corn 
and the pellagrous laborer fed on spoiled corn hang 
on the walls of public lecture halls; and the pella- 
grologic and agricultural commissions of the dif- 
ferent provinces multiply instructions by precept 
and example." (Cutting.) 

The results of such work seem on the whole very 
encouraging, but their interpretation is difficult by 
reason of other contemporaneous developments. 
They coincide with a marked rise in general pros- 
perity. The laborers and peasants can now eat bet- 
ter food than ever before; numbers of the rural 
population are employed in industrial institutions, 
where they receive a varied diet ; temporary emigra- 
tion has reflexly widened the view of the peasant 
class, and they demand and get better food and 
living conditions; the consumption of meat is in- 
creasing, and wages are higher. Such things must, 
of course, in a disease like pellagra, have a very 
profound effect. 

Statistics undoubtedly show a decrease in pel- 
lagra; but for many reasons statistics are not 



COMMTJNICABILITY 

entirely satisfactory and do not serve to show the 
actual state of the case. The opinions of those 
actively engaged in the work and in close touch with 
the situation, are, in general, that pellagra in Italy 
is notably decreasing both in numbers and in inten- 
sity. Strange as it may seem, however, the disease 
is apparently increasing its area, and parts of Italy 
previously free from pellagra are now developing 
the disease. The cause of this is not apparent. 

C ommunicability . The question of the contagi- 
ousness of pellagra, early in its history, aroused 
much discussion. The idea of contagion was advo- 
cated by many able men, and opposed just as 
strongly by others. With the courage of conviction 
and with the zeal of enthusiasts, several voluntarily 
submitted themselves to inoculation with pellagrous 
material in order to prove their contention of its 
non-contagiousness. The inability of those favoring 
contagion to bring forward any satisfactory reasons 
or observations to sustain their view, and the numer- 
ous observations and the extended experience of 
others against the idea of contagion, at last served 
entirely to discredit any doctrine of communica- 
bility; and the advocates of contagion abandoned 
their views. Since then this subject seems to have 
received but scant attention at the hands of writers 
on pellagra, the question being regarded as defin- 
itely settled. Roussel, as early as the middle of the 
nineteenth century, wrote: "It can be said of the 
contagion of pellagra, that it is a question fully 
determined, . . . pellagra is not contagious." 



300 PELLAGRA 

This question has very naturally arisen again in 
the United States, and observations have been 
brought forward in support of communicability ; 
measures of isolation and quarantine even having 
been adopted. 

Such views seem to us now wanting in proper evi- 
dence to support them. Of course we must realize 
that the medical profession has many times been led 
into error through what appeared to be sound de- 
ductions from extensive observations ; and so long as 
the etiology of pellagra remains in its present state 
it can not be denied, beyond all doubt, that communi- 
cability in some form may be a possibility. This is, 
however, too severe a test to apply to a great deal 
of accepted medical opinion. In the present state of 
our knowledge, the idea of communicability seems 
to us indefensible; and the hardships and severity 
always implied in quarantine and measures of iso- 
lation appear equally unjustifiable, either on theoret- 
ical or practical grounds. 

Treatment. 

Regarding fthe medical treatment of pellagra, 
Holland, as long ago as 1817, wrote: "In short, it 
appears certain that mere medicine has done very 
little for the relief of pellagra; and Strambio 
frankly confesses that he never saw a case distinctly 
cured by the remedies that were employed." 

This gloomy outlook has been shared by others, 
and here in America most clinicians who have had 
experience with the disease seem inclined to take a 
very discouraging view of treatment. 



TREATMENT 301 

Certainly we must admit at the outset that we 
have no specific for the disease, but this is far from 
admitting that treatment is hopeless. In great part, 
the present therapy of pellagra is founded on Lom- 
broso's teaching, and while he, and his followers, 
may by many be regarded as too sanguine, still his 
enormous experience certainly entitles his views to 
the greatest attention and respect. In discussing 
the treatment of pellagra in accordance with ideas 
advanced by him, he says that the therapy of this 
disease, which was at first desperate and could be 
summed up in baths barren of result, can now be 
undertaken more confidently and rationally, as the 
treatment of a chronic intoxication, analogous to 
alcoholism or morphinism, and curable by antidotes, 
when the use of the toxic material has been sus- 
pended. These antidotes, he thinks, are to be found 
in arsenic and chloride of sodium. 

Lombroso's teaching has had a profound effect, 
and his ideas on therapy have been very generally 
adopted. No account of treatment, therefore, would 
be complete without at least a brief review of the 
measures advocated by him. 

He recommends as a rule a liberal diet, including 
meats especially, but points out that this alone is 
insufficient. He also remarks that in well -nourished 
pellagrins this is of course not so much indicated, 
and adds that such cases are rebellious to treatment. 
He speaks of baths and cold douches, which he 
thinks benefit especially paretic states, the skin man- 
ifestations and the painful burning sensations so 
common in pellagrins; and further says that, while 



302 PELLAGRA 

they do not cure, they at least prolong existence or 
render it more tolerable. In some patients, however, 
there is a true aversion to baths, and in such they 
should not be tried. 

Of drugs in a general way he condemns the use 
of iron, for the reason that he has seldom seen bene- 
fit from its use and has often seen it cause exacer- 
bations of intestinal and other symptoms. In some 
cases, especially in the young and those with arrested 
development, he states that he has obtained magnifi- 
cent results with simple salt rubs or frictions. He 
has experimented extensively with acetate of lead, 
but finds it of little use except in pellagra of the 
aged, in those who suffer acute articular pain, in 
cases of incipient paresis, and in cases of general 
tremor. The dose used was 0.01 to 0.05 gram in 
300 c. c. of water. In typhoid pellagra he tried 
numerous remedies without avail. 

Finally in his search for a remedy (through some 
reports of Coletti and Perugini) he got the idea of 
using arsenic, and he says, after experience with the 
drug, that the results exceeded by far his expecta- 
tions. He does not seem to regard arsenic as a true 
specific for pellagra and admits that it does not cure 
all cases, but he thinks it is a very valuable remedy t 
and that it acts in a certain sense as an antidote for 
the toxines of spoiled maize. As an antidote he 
compares it to the action of opium in alcoholism and 
mercury and the iodides in syphilis. Sodium 
chloride he seems to think has probably an equally 
powerful effect, but a very much more restricted 
field, being limited largely to children. 



TREATMENT 303 

He uses arsenic in the form of Fowler's solution 
in dosage of 5, 10, 15, 20, and 30 drops, or in the 
form of pure arsenous acid (arsenic trioxide) dis- 
solved in slightly alcoholized water, in doses of one- 
fortieth to one-twentieth milligram, increasing, 
according to tolerance, up to 0.001, 0.002, or 0.003 
gram and very rarely even to 0.01 gram. The ad- 
ministration of the drug is suspended for a few days 
from time to time. He cautions against certain 
dangers in its use, however, and mentions as dan- 
gerous symptoms the appearance around the neck 
of an herpetic eruption, profuse salivation, ano- 
rexia, vomiting, diarrhea, palpitation of the heart, 
syncope, burning in the pharynx and stomach, head- 
ache, great muscular weakness, and bronchitis. The 
possibility of arsenical neuritis should be kept in 
mind. 

He thinks certain types are especially helped by 
the administration of arsenic, and that certain others 
receive no benefit, as follows : 

Benefited. — Cases with marked marasmus; cases 
with incipient paresis; cases with sitophobia (gas- 
tralgic type) ; cases with vague mania but not sys- 
tematized delirium; cases in the aged, if not at the 
verge of decrepitude. 

Not benefited. — Cases in the young and in infants ; 
cases well nourished and robust; cases with system- 
atized delirium; cases with mental alienation of 
twenty to thirty years' duration ; cases having lobar 
pneumonia, tuberculosis, albuminuria, or severe 
vertigo. 

In cases of grave vertigo he sometimes uses the 
tincture of cocculus orientalis in doses of 3 to 5 
drops daily, progressing slowly to 30 drops a day. 

20— P. 



304 PELLAGRA 

Among symptomatic remedies he seems to approve 
the use of calomel, castor oil, bismuth subnitrate, 
opium, tannin and other astringents, at times 
chlorate of potash and astringent enemas in the 
treatment of the diarrhea. In certain advanced 
cases ergot, strychnine and faradism have sometimes 
been employed as useful adjuvants, and in alienated 
cases such hypnotics as chloral, paraldehyde and 
sometimes opium. 

In defending his use of arsenic and salt he con- 
tends that on empirical grounds alone he can be jus- 
tified, since experience has amply proven these rem- 
edies to be of immense benefit. But he further- 
more states that their use can be justified on 
rational grounds as well, and he quotes extensive 
experimental work to show the beneficial effects of 
arsenic on the heart, skin and nervous system, its 
antifermentative power, its effect on metabolism, 
etc. ; for chloride of sodium he brings forward similar 
evidence to show its action on the skin, its power of 
aiding in the assimilation of phosphates, increasing 
muscular force, aiding digestion, stimulating the 
development of cartilaginous and other tissues, its 
beneficial effect on the nervous system, etc. 

The general measures adopted in the treatment 
of the disease should be dietetic, hydrotherapeutic 
and medicinal. 

The diet is a matter of much importance and 
should be selected with some care. It should be 
easily assimilable, highly nutritious and should 
include meats. An abundant diet is recommended 
in spite of the frequent intestinal disturbances and 



TREATMENT 305 

diarrhea. These disturbances are perhaps trophic 
largely, and not inflammatory, in their nature; and 
food is not so much contra-indicated as in some 
other intestinal states. Of course if the diarrhea is 
too free and the stools contain undigested material 
the diet must be regulated accordingly. It must not 
be forgotten, however, that the patient's condition 
usually requires all possible nourishments and effort 
must not be spared in the individual case, where 
possible, to meet the dietetic indications. Of course 
in the treatment of a number of pellagrins, as in 
institutions, the question of expense or feasibility 
often intervenes. The general diet given adults, 
for example, in the locanda sanitaria at Bagnolo 
Mella. in Italy, is as follows: First meal: meat 
broth, and coffee and milk, each on alternate days, 
with 150 grams of bread. Second meal : one liter of 
soup made of macaroni, 100 grams, vegetables, 100 
grams, meat stock and condiments; boiled meat, 200 
grams, with vegetables, 50 grams ; bread 300 grams ; 
wine 200 grams. Third meal : ]/ 2 liter of soup, made 
of rice, 50 grams, vegetables, 50 grams, meat stock 
and condiments; meat stew, 100 grams, with vege- 
tables, 50 grams; bread 150 grams; wine 200 grams. 
This diet is modified in many ways to suit individ- 
ual cases and appetites, and for children under 
twelve years is reduced in quantity. 

In commenting on this diet Ceresoli, the medical 
director, states that digestibility, which is to a large 
extent dependent upon cooking, is a matter of great 
importance; and for this reason he commends 
roasted meats, which for local reasons he has not 



306 PELLAGRA 

used in his diet. Where there is repugnance to 
meat he substitutes cheese or eggs, and cheese he 
recommends highly. The wine, which is of good 
quality, stimulates a torpid digestion. Care is 
always taken by him that dietetic rules are subor- 
dinated to age, sex, temporary physiological acci- 
dents, idiosyncrasies, the condition of the gastro- 
enteric tract and to the greater or less tolerance of a 
reconstructive food supply. He also points out the 
especial need for nitrogenous substances in a diet for 
pellagrins. He seems to think it no easy matter 
nicely to adjust a diet to the needs of these sufferers, 
and that a diet, begun cautiously, can be gradually 
and judiciously enlarged properly to meet their 
needs. 

Hydrotherapy is considered a valuable adjuvant 
in the treatment of pellagra and is extensively em- 
ployed. Cold baths and warm baths, both simple 
and medicated, as well as douching, are employed. 

Such treatment must be used with discretion, of 
course, and consideration given to the stage of the 
malady, predominating symptoms, therapeutic indi- 
cations, age, sex, and general physical character- 
istics. In weak and prostrated individuals treat- 
ment is begun with warm baths of short duration, 
and the temperature is reduced and the time pro- 
longed as the patient improves. At the extremes of 
life the warm bath is preferable. 

The application of baths should be so regulated, 
of course, as to produce the best results, with in- 
creased oxidation of the tissues, more rapid elimina- 
tion, greater metabolic activity, increased appetite, 



TREATMENT 307 

improved digestion and assimilation, and a strong 
tonic effect on the whole organism. Improvement 
is evident from increase in weight, in the firmness 
and force of the musculature, disappearance of 
prostration and subjective nervous symptoms, with 
increased physical and moral vigor. 

Vertigo, stuporous states, distressing paresthesias 
and even diarrhea are often benefited. Massage may 
sometimes be added with advantage. 

The medicated baths of sulphur or arsenic are 
used chiefly in certain conditions of the skin, some- 
times in cases with predominating intestinal disturb- 
ance accompanied by wasting. 

The salt bath or rub is of especial importance in 
children. This may be given as follows : The child 
is placed in a tub of warm water, the temperature of 
which may be practically judged by the hand, which 
should be able to bear it with comfort. A conve- 
nient receptacle of salt is placed near. The salt 
should be of a fine quality and should not contain 
coarse particles. A good kitchen or cooking salt 
answers all requirements. The attendant, having 
stood the child up in the tub, wets his hands and 
dips up a handful of the salt. With this he thor- 
oughly and firmly, but not roughly, rubs the child's 
body all over for seme fifteen or twenty minutes. 
The child is then made to lie down in the water, the 
salt is washed off, and after a few minutes a cold 
douche is given. The child is then put to bed and 
at rest for a time. This may be done three or more 
times weekly. 



308 PELLAGRA 

For further details concerning hydrotherapy 
the reader must consult special works on the subject. 

Among general measures rest is a matter of much 
importance, especially in acute conditions, and when 
there is fever. Change of climate and surroundings, 
if possible, particularly to colder latitudes, may be 
advised. Saline infusions may at times be of service. 
During the warm season avoidance of the sun's 
direct rays may prevent a bad erythema. Cleanli- 
ness, good nursing and fresh air are, of course, to be 
desired. 

With regard to the medical treatment, symptom- 
atic remedies must be used as needed. For insomnia 
chloral hydrate, paraldehyde, or some of the more 
recent hypnotics, like trional, sulfonal or veronal, 
may be tried. The dermatitis, if dry, may not 
require much attention, but moist dermatitis, espe- 
cially if extensive, cause much inconvenience. Such 
surfaces often become infected and may prove of 
no small concern. Oily applications or tincture of 
iodine may be used on dry surfaces. The moist con- 
ditions should be treated on general surgical prin- 
ciples. We have found a picric acid dressing (1 per 
cent, aqueous solution) of benefit, but it stains linen 
badly. A stubborn diarrhea will give much trouble 
at times and may prove rebellious to all treatment; 
the bismuth salts, the salicylate especially, various 
astringents, sometimes enemas of cold water, and at 
times opium along with the general and dietetic 
management, must be depended on for its control. 
Pain may at times require morphine, but we have 
not been forced to resort to its use to any great 



TREATMENT 309 

extent, and it is, of course, to be avoided if possible. 

Complications, such as malaria, syphilis, intes- 
tinal parasites, should receive prompt attention with 
appropriate remedies. If much anemia be present 
many good observers think a bland preparation of 
iron is needed; some good preparation of arsenate 
of iron would seem of value, and such a preparation 
can now be obtained even for hypodermatic use. 
Mercury, except in cases complicated with syphilis, 
seems valueless. Following Wright's work with the 
succinamide of mercury in tuberculosis, we have 
given this salt a trial in several cases, but achieved 
no results except in syphilitic cases. The remedy 
proved quite irritating locally. 

The more or less recent introduction of certain 
new arsenical compounds seemed, in the light of 
Lombroso's work, to offer a better therapy for pel- 
lagra. Of these preparations three have come into 
more or less general use. These go by the names of 
atoxyl, soamin and arsacetin. Atoxyl and soamin 
are both trade names and are stated to be forms of 
sodium arsanilate, containing respectively about 26 
per cent, and 22 per cent, of arsenic. They are sold 
in the form of the salt itself or in the form of 
hypodermic tablets. Arsacetin, introduced by Ehr- 
lich as an improvement over the other two, is 
described as an acetyl derivative of atoxyl. This is 
sold in the form of the salt itself. 

The arsenic of these salts is said to be liberated 
very slowly in the system, thus producing the ordin- 
ary therapeutic effects of arsenic with the advantage 
of a more continuous and less toxic action and less 



310 PELLAGRA 

irritation. Toxic effects from excessive dosage have 
been frequently noted, although their toxicity is 
far less than that of arsenic trioxide. Blindness, 
due to degeneration of the optic nerve, has occa- 
sionally resulted. 

All of these salts are soluble in water, arsacetin 
more so than the others, and they are largely used 
by the hypodermic or intramuscular method, their 
administration by mouth not being recommended 
for the reason that toxic symptoms may result from 
decomposition by the acids of the stomach. 

There has been much discussion as to the dosage 
of these remedies, but based on the extensive use of 
atoxyl and soamin in syphilis and trypanosomiasis, 
it would seem efficient and safe to give as much as 
0.5 to 0.65 gram on each of two succeeding days, and 
to repeat this dosage, with ten-day intervals, for 
many months. Others have given as much as 0.5 
gram on alternate days until 7 grams have been 
given, then a rest for three months. The dosage of 
arsacetin is stated to be lower, but many workers 
have used the same dosage as with the other salts, 
without toxic results. Arsacetin has the advantage 
of being more soluble, is said to be less toxic, its 
solutions can be boiled and they keep well. It is 
perhaps needless to add that in administering these 
remedies antiseptic precautions should be observed, 
and local irritation thus avoided. 

Babes, in Koumania, seems first to have used 
atoxyl in pellagra and reported very favorably on 
his results. Warnock, in Egypt, then tried it ex- 
tensively, and concluded ultimately that "the value 




riato XIX. South Carolina case. "Wet" form. Lesions identical 
with those of Plate XVIII. Both eases under observation at same 
time and both rapidly fatal. 



TREATMENT 311 

of atoxyl in the treatment of advanced stages of pel- 
lagra such as are met with in this asylum has not 
been demonstrated," and he could not confirm the 
Roumanian experience. 

Reports on the use of these remedies in the United 
States have been almost universally unfavorable. 
We have used both soamin and atoxyl rather exten- 
sively, but have had only a limited experience with 
arsacetin. We have used them almost exclusively 
by the intramuscular method, and have observed no 
toxic effects except in one case. Our usual dosage 
has been 0.5 to 0.65 gram on alternate days for two 
to three doses, then a rest of ten days, and repeat for 
several weeks. Our work has largely been done 
with asylum cases, and the results have been disap- 
pointing. With a few non-asylum cases, however, 
we have noted improvement; and we are not in- 
clined, as yet, to discard these remedies as useless. 
Inveterate diarrheas have seemed at times to yield 
to atoxyl or soamin. 

Recently Babes, and others, have reported bril- 
liant results from the use of atoxyl and arsenic tri- 
oxide combined. The method is as follows : Atoxyl 
0.5 gram hypodermatically ; externally on the sound 
skin, a rub with 5. grams of an ointment of arsenic 
trioxide (1 to 50) : and internally a pill of arsenic 
trioxide (.001 to .002 gram) thrice daily; this treat- 
ment is given on two successive days, and, if neces- 
sary, is repeated once after an interval of one week. 
We have given this method a limited trial, but with- 
out observed benefit. 



312 PELLAGRA 

We have used Fowler's solution of arsenic in 
many cases with apparently good effect. Donovan's 
solution has likewise been employed by some. It is 
needless to add that scores of other remedies have 
been employed and recommended in the treatment 
of pellagra, but they have not borne the test of time. 

Finally, we have the serum treatment and blood 
transfusion. There is a good deal of evidence tend- 
ing to show that specific antibodies are developed in 
the blood of pellagrins, and the serum of recovered 
cases has been reported as successfully used in the 
treatment of typhoid pellagra. Some workers have 
even expressed the confident hope of producing from 
the horse an efficient antiserum, but this has not yet 
been realized. It has also been suggested that pos- 
sibly so-called "blind staggers" in horses may be 
pellagra, and that the serum of animals recovered 
from this disease may be efficient in treatment. 

We have attempted to treat two cases with blood 
serum taken from recovered pellagrins. One case 
died from a pneumonia shortly after treatment was 
begun, the other seemed to improve for a while, but 
finally, after much emaciation, died of an intercur- 
rent tubercle of the lungs. It is difficult to secure 
proper cured cases, otherwise such treatment is not 
difficult to carry out, and would seem well worth 
further effort. 

Cole has treated a number of cases by blood trans- 
fusion, after Crile's method, and reports very good 
results. For donors he has used both recovered pel- 
lagrins and others who have not had the disease. 
This procedure, while not difficult, requires expe- 



TREATMENT 313 

rience. It is more difficult of application among the 
insane by reason of lack of cooperation on the part 
of the patient. Under certain conditions it may be 
regarded as a valuable surgical resource. 

The benefits of a change of climate- were long ago 
recognized by the Italians and French and recently 
have been recommended in this country by Bass and 
others. 

In conclusion, it may be said that treatment of 
advanced stages of the disease, especially in asjdums, 
is very unsatisfactory. Early cases, without mental 
involvement, however, can be often successfully 
reached. Furthermore, in a disease like pellagra 
where so many persons are involved, especially 
among the poorer classes, the great desideratum is, 
of course, some specific treatment, inexpensive and 
easy to use. Elaborate and expensive measures do 
not fulfil the indications; and while such resources 
are of great value under certain rather exceptional 
conditions, they are, for general use, largely inap- 
propriate. 



CHAPTER X 

Corn and Pellagra in France. Roussel and 
Lombroso. 

It would seem evident from what has been said 
that the prime necessity in the prophylaxis of pella- 
gra would be a radical change in dietary, but the 
practical question at once arises as to the means to 
be adopted in carrying out this reform ; and the fur- 
ther difficulty as to whether corn, even if sound, 
should be interdicted. This immediately suggests 
an inquiry as to the food value or danger of corn 
of good quality. 

Food Value or Corn. 

Not a few have asserted that pellagra may be due 
to a scarcity of nitrogenous material in corn, a 
scarcity all the more pernicious for that class of 
people like the peasants (in whom all admit a 
greater frequency of pellagra) who must constantly 
do severe manual labor. 

An attempt has been made to justify such an 
hypothesis from the less intensity of the disease 
among those who eat meat, like the city dwellers or 
the rich ; and from the preference which is even yet 
given by the physiologists to nitrogenous food over 
a vegetable diet ; such considerations stimulating the 
belief that a lack of meat is dangerous to human 
health. 

Lombroso has shown how almost all the laboring 
classes and peasants of Europe live upon a vegetable 
diet; and likewise the laboring populations of other 
nations as, for example, the Chinese and Japanese. 



FOOD VALUE OF CORN 315 

As Beketoff* has said: "The physiologists have 
exaggerated certain statements on dietetics. They 
have not taken into consideration that there are 
immense masses of people who live contrary to their 
dicta and still perform labor. 

"Man has not the teeth of the carnivora; the 
length of his intestines is six times the length of his 
body; just as the ape, essentially fructivorous, has 
not a carnivorous structure. Moreover, a meat diet- 
ary is not as widespread as is supposed ; it is rather 
the exception than the rule. Whereas the English- 
man eats on the average 100 grams of meat per day, 
the Frenchman eats but 35 grams, and only the 
Frenchman of cities at that. If meat diet were 
much extended, the lack of meat would become an 
insurmountable obstacle. The number of domestic 
animals is diminishing, and if all those in existence 
today were slaughtered, it would furnish for each 
inhabitant of Europe 400 grams of meat for one 
year, and no more. 

"All humanity may be divided into those who 
subsist on rice, on corn, on wheat, and on rye; the 
meat eaters representing a small minority." 

If the opinion were correct that lack of meat as 
food is the cause of pellagra, then all humanity would 
be pellagrous, including the peasants of Sicily and 
Sardinia, who, for whole months, eat only lettuce 
and figs ; and the Japanese, who eat almost nothing 
but rice, and rice contains even much less of hydro- 
carbons and albumenoids than does corn. It must 
not be concluded from this that these persons remain 

•Revue scientifique, 1881. 



316 PELLAGRA 

free from disease (beriberi) because they work less 
than the Italian peasant, or because they eat more. 
The Norwegian lumberman himself accomplishes 
his severe toil, as Virchow remarks, on a quantity 
of dry bread and cheese so small that one would 
scarcely believe it. 

Kingsford observes, with reason, that the animals 
that do the most severe labor, and are continually 
harnessed, such as horses, cattle, elephants, live on 
plants; and that the Grecian athletes ate only figs, 
nuts, cheese and bread. The Egyptian porters live 
on melons, onions, lentils and dates; and the 
Japanese day laborers live on rice, fruits, roots and 
herbs. 

In France, according to Rochard (Bertillon), the 
vigorous vine growers of Nievre eat meat onty once 
a year, and the peasants of Morvan twice. 

Some have urged as a cause of pellagra the exclu- 
sive use of one food, but they have overlooked such 
instances as that of upper Italy, where certain peo- 
ple live among fruit trees and dairies. One result 
of a personal investigation among the population 
of the country in pellagrous regions has been the 
demonstration of the falsity of this assertion, 1 and 
this appears still more clearly from the splendid 
researches of Bodio. 2 

In Villempenta, a region much affected by pella- 
gra, the ordinary food consists of wheat cakes 



^ombroso, Sulle Condizioni eeonomicoigieniche dei contadini dell' 
olta e media Italia, Milano, 1877. 

2 Sui Contratti agrarii e Sulle Condizioni Materiali di vita dei 
contadini d' Italia, 1870. 



FOOD VALUE OF CORN 317 

cooked with oil or lard, rice, fish and pork, besides 
corn in the form of pancakes and polenta. 

At San Martino alp Argine, a place where pel- 
lagra is frequent, the nourishment is polenta, cheese, 
sardines, besides annually nine sacks of corn and 
three of wheat for every able-bodied laborer. At 
Mel. in Belluno, fifty per cent, of whose population 
is pellagrous, the food is polenta, cheese, milk, often 
beans and chestnuts, and on feast days, macaroni 
and rice. 

In the province of Lucca, the villages most 
affected eat beef and pork. Ceru gives these sta- 
tistics: 

Beef Pork Total Meat 

Population. Butchered. Butchered. Butchered 

Porcari 4,621 5,600 kg. 26,333 kg. 31,933 kg. 

Capanneri.. | 4,222 8,000kg. 20,533kg. 28,533kg. 

Fossignano. f 4,222 8,000 kg. 20,533 kg. 28,533 kg. 



Bodio says that the food of the inhabitants of the 
country districts around Cremona consists of polenta 
with a little pork, fish and rice. In Coresina rice 
and vegetable soup, polenta with cheese and vege- 
tables, kneaded bread, etc. 

In Melegnano, Pavesi found, after careful exam- 
ination, that the population consumed each week 
per head : 

Rice or Corn in Soup 1,332 grams 

Corn Bread 1,350 grams 

Beans 232 grams 

Fat 332 grams 

Vegetables 133 grams 

Other Starchy Material 992 grams 

Proteid Substances 160 grams 



318 PELLAGRA 

Jacini, in his classic work on landed estates, says 
that in lower Lombardy, at the height of the sum- 
mer, they give daily, to a domestic, 2 lbs. of corn; 
in winter 1 1-2 lbs., and in addition two to three 
measures of milk, two rice soups, and on Sunday 
sausages. The younger domestics have the same diet 
except the milk. 

Calderini also says that out of the pellagrous suf- 
ferers visited by him, who took meat diet, 18 
per cent, of the women, and 41 per cent, of the men 
ate meat on Sunday, 87 per cent, daily took milk, 17 
per cent, took wine, and 33 per cent, wheat bread. 

According to the facts noted in the report of 
Friuli, by the Engineer Camis: "In a population, 
which numbers 3 per cent, of pellagrins, each peas- 
ant consumes annually, besides 372 kilograms of 
corn, from ten to ninety kilograms of each of the 
following: beans, rice, potatoes, and other vege- 
tables, pork and bacon, olive oil, fish, chickens and 
wine. They do not eat beef except on festal days, 
for a marriage or an illness, or when an animal of 
the herd dies." 

In the province of Ferrara an adult hired peasant 

consumes on an average daily : 

During severe 
Usually (eight labor (four 
months of the months of the 
year. ) year. ) 

Polenta 1,000 grams. . . 160 grams. 

Milk Almost none — Almost none. 

Eggs One-fifth A half. 

Onions One Two. 

Wheat Bread 50 grams. . . 400 grams. 

Macaroni 50 grams. . . 200 grams. 

Meat (principally pork) 10 grams. . . 60 grams. 

Cheese 5 grams ... 20 grams. 

Beans 150 grams. . . 40 grams. 

Fish 20 grams . . . Almost none. 






FOOD VALUE OF CORN 319 

Apart from its readiness to undergo change, corn, 
from a physiological standpoint, is an excellent food. 
But experience has proven that even so good a food 
as corn cannot, without harm, be continued exclu- 
sively for a long time. 

Agricultural experiments have shown, however, 
that animals fed on corn alone may fatten. For 
example, Guffart succeeded in fattening some hun- 
dreds of cattle on selected corn alone, although he 
found it much better to mix therewith forage 
or oat straw : 12 cows weighing 2,207 kilograms, 
attained, after being fed on corn alone for 156 days, 
159 kilos per day, the weight of 2,951 kilograms. 
Eight cows, which in 453 days, had consumed 12,063 
kilos of corn, along with 2,935 kilos of oat straw, 
increased from 3,549 kilos to 3,996. 1 

Dankoff has proven in his recent work that many 
ruminants perish if they are given the same food, 
as oats or turnips, for more than three months. 
That is due to the fact that the same food continued 
monotonously, surfeits and destroys the appetite; 
it is sufficient to change the diet and all danger is 
gone. 2 

Experience teaches us that the poorest laborer 
varies his diet on occasion of the smallest festival. 
One would therefore "err if he pointed out as an 
etiological factor a diet insufficiently varied. It 
would be regrettable if the government, in fighting 
pellagra, should resort to the distribution of meat 
rather than establishing drying ovens and granaries 
for corn. 

iManuH fl(> In culture da mnis, 1870. 

a Areh. Anatomie et Thysiologie, 1881, i> 433. 



320 



PELLAGRA 



If it is claimed that corn does not contain enough 
of the essential nutritious substances, or, at least, 
that it contains them in smaller quantities than other 
cereals, an answer may be found in the following 
tables of Guhring, of Bell and of Koenig and 
Dietrich : 

COMPARISON OP CEREALS BY GUHRING. 







fro 






0) w ? 


•a 

a 

83 


■SoJ 

as 


aJ 




u 

0) 
+J 


2| 


2 
"3 

o 


+- 


83+-. A s 


+- T3 
O O 


43 c 


o 

3 




Hrc 


(k 


h 


Kffi^ti 


f-lt» 


Ph^ 


o 


Wheat flour 


13.6 


86.4 


12.0 


1.1 


72.3 


0.173 


0.249 


0.5 


Rice meal 


10.03 


89.97 


11.7 


2.0 


48.6 


2.228 


3.939 


15.0 


Corn meal 


10.0 


80.0 


15.2 


3.8 


70.5 


0.220 0.306 





[For comparison, the following table taken from 
Bell's analyses, 1 may be added : 



Constituents of 


the Grains of the 


Common 


Cereals. 




u 

+J v ^ 

>& 9. 


>> 

o 

"3 

84 

M 


09 
83 
O 


3 




6 

2 


♦Starch 


63.71 

15.53 
3.03 

2.57 

1.48 

1.60 

12.08 


63.51 

11.46 
7.28 

1.34 

1.03 

2.32 

13.06 


49.78 

14.67 
13.53 

2.36 

5.14 

2.66 

11.86 


64.66 

14.27 
1.86 

1.94 

3.58 

1.35 

12.34 


61.87 

14.87 
3.23 

4.30 

1.43 

1.85 

12.45 


77.66 


Nitrogenous matter 
(i. e., albumen, ce- 
realin, etc.) 

Cellulose 


9.34 

Traces 


Sugar (saccharine 
body allied to cane 
sugar) 


0.38 


Fat 


0.19 


Mineral matter 


0.28 
12.15 






Total 


100.00 


100.00 


100.00 


100.00 


100.00 


100.00 







♦The starch includes from 1 to 1.5 per cent, of dextrim, and 
together with cellulose and sugar, comprises the carbohydrates of 
the cereals.] 

x Quoted from Kenwood — Public Health Laboratory work, Lon- 
don, 1908. 



PROPHYLAXIS 321 

PERCENTAGE COMPARISON OF CEREALS ACCORDING TO 
KOENIG AND DIETRICH. 

Non-Nitrogenous Fatty 

Extractives. Substances. Proteids. 

Rice 72.47 1.76 8.38 

Corn 65.43 5.56 9.90 

Rye 65.16 1.96 13.31 

Wheat 68.85 1.55 12.66 

Irish potatoes 21. 0.15 2.17 

The opinion that corn is dangerous because diffi- 
cult of digestion is without foundation. According 
to the above table of Koenig and Dietrich, and 
according to the demonstration of Uffelmann in his 
Hand-book on Hygiene, the nitrogenous substances 
contained in corn are very much more digestible 
than those of wheat bread, rye bread and Irish pota- 
toes. It may be added that according to Letheby, 
the quantity of nitrogenous matter contained in oats, 
barley and rye has a value of 1.90 francs, while in 
wheat bread it has 2.21 francs, in rice 3.80 francs, in 
potatoes 2.77 francs, in milk 7.39 francs, in pork 
8.87 francs, and in corn 1.08 francs. 

Prophylaxis. 

From all the proofs given that feeding upon 
spoiled corn alone is the cause of pellagra, there 
would seem a very definite and certain means of 
prophylaxis. 

To tell a peasant, as many do, that, if he wishes to 
protect himself against pellagra, he has only to have 
a good dietary, and then drink more wine, is correct; 
but this advice is useless, harmful and even cruel 
irony. When one treats pellagrins at home, it is 



322 PELLAGRA 

more difficult to nourish them with bread, meat and 
corn, than merely to give them counsel. They will 
continue to eat corn because they have no better, 
and cannot get any better ; and the chances are that 
there is, in the corn they have, a variable but decided 
proportion of spoiled grain. If the unhappy peas- 
ants of Lombardy were able to have a better diet, 
they would have it without the advice of the phy- 
sicians, says Lombroso, and they would not have 
pellagra. Good diet, however, will never eradicate 
pellagra. The first therapeutic effort in the treat- 
ment of pellagra ought, nevertheless, to aim at the 
suppression of the cause of the trouble, that is, the 
dietary of spoiled corn, a thing easy to secure in 
hospitals. Clinical experience and pathological 
anatomy demonstrate that pellagra does not come 
from lack of proteid in corn, but from the use of 
corn which has become spoiled. As we have already 
said, corn, in proportion to its price, yields a quan- 
tity of nitrogen larger than that of any other 
aliment with the exception of beans. [Pellagra is a 
morbid entity, entirely distinct from mere inani- 
tion.] 

One should not, then, forbid corn to the peasant, 
but counsel him to harvest and preserve it in such a 
manner that it cannot spoil. 

With regard to general prophylactic measures, 
various suggestions may be made. Ameliorate or 
change the various modes of corn culture according 
to the region; for example, the culture of quaran- 
tina may be suppressed where corn ripens badly 
or is harvested too soon and, therefore, does not 



PROPHYLAXIS 323 

become thoroughly dried; the corn called "dwarf 
corn," or "chicken corn," which matures more read- 
ily, may be substituted for it. In sandy ground the 
cultivation of white corn, which does not grow well 
there, ought to be abandoned from economical 
motives as well as for hygienic reasons. 

Intensive culture can be carried on only by means 
of irrigation, but then in certain districts watering 
costs from 25 to 50 francs per hectare. 

If, according to experienced farmers, in the place 
of quarantina, potatoes were planted, there would 
be a more profitable crop. Irish potatoes yield 100 
hectolitres per hectare; the quarantina only 36; 
then, the bad weather does not spoil the potato crop 
as it does that of corn; finally, if you reckon 500 
francs for seed, and eliminate the fodder, the pota- 
toes would still yield a greater profit by 100 francs. 

Other writers recommend millet in the place of 
potatoes. It is very nourishing, but does not yield 
so well as potatoes and it exhausts the soil. 

In regions where it rains regularly at the time of 
the harvest, there would be needed a place paved 
with good stones or with cement, with spacious room 
for storing the cereals after drying them in the sun. 
One could follow the example of the peasants of 
Mexico, where, after the harvest, they expose the 
grain to the sun during the day and put it under 
shelter again at sunset. 

It would be worth while to set up co-operative 
machines for shelling, and in this way the corn of 
the small farmers would be as quickly shelled as 
that of the large proprietors, without being more 



324 PELLAGRA 

exposed to inclement weather. This would mean 
economy in wages. On the small farms it would be 
sufficient to have movable frames for exposing the 
ears of corn to the sun, as is done in the Tyrol, 
Tuscany and Liguria. 

The system of preservation ought to be completely 
changed. In most of the great public or private 
granaries of upper Italy, they should make general 
use of the means which, in the approval of all 
Europe, preserves the corn from dampness, fermen- 
tation, mice and worms, and which considerably 
diminishes the losses during preservation. 

To the apparatus of Devaux is due the freedom 
from pellagra enjoyed by the Irish, who, in later 
years have to some extent substituted the use of 
corn for potatoes in their dietary. This apparatus 
consists of a series of light iron frames or boxes, 15 
meters high and 1.67 meters wide, each perforated 
by small holes like a skimmer, and the whole tra- 
versed from below upward by a tube or cylinder 
likewise perforated. The grain, through which the 
air must pass, is never placed in layers deeper than 
65 to 70 centimeters, so that the air may easily per- 
colate. The air is heated and pumped through the 
apparatus by means of steam. While with ordinary 
methods of preservation there is expended from 1.50 
even to 3 francs per hectoliter without obviating a 
loss of 8 per cent, to 16 per cent, through spoiling of 
the grain, or through the evaporation which follows 
heating, yet with this apparatus preservation costs 
only 7 or 8 centimes per hectoliter, and there is no 
greater loss in the weight and value of the grain. 



PROPHYLAXIS 325 

The Pavy granary renews the air, drys and cleans 
the corn at a cost of 1.50 francs per hectoliter. For 
large landed estates the granary ventilator of Valery 
is suitable. 

Similar apparatus ought to be installed on board 
those ships which transport cereals, and on which 
corn is piled up unprotected and exposed to rain. 
A great increase of pellagra in Italy, in 1853, was 
due to corn imported from Odessa, which was 
exposed to continuous rains during transportation. 

In regions with a dry soil the corn containing less 
than 16 per cent, of water can be preserved in tight 
receivers communicating with the air (silos of 
Romagna). The millers and bakers could use very 
simple arrangements like the screens used in 
Mexico. 

New industrial applications for the use of corn 
other than its use for human food should be 
encouraged. For example, the manufacturing of 
spirits or alcohol, and above all, the feeding of stock. 

Premiums ought to be accorded to inventions 
which improve the baking of corn bread and its 
preservation in the ordinary bakeries. 

Laws ought to forbid the grinding and selling of 
mouldy corn. Oversight ought to be organized in 
the country at the time of harvest, and in the cities 
over the great warehouses at the time of summer 
heat. Severe fines ought to be prescribed against the 
proprietors who oblige their laborers and small 
farmers to eat spoiled corn. These prohibitions 
were already in force in Venetia as early as 1776 
(See Appendix III) , and are still so in Austria. But 



326 PELLAGRA 

in consequence of acquittals, a fine for selling spoiled 
food does not attain its end, and indifferent public 
opinion neutralizes the good effect of the laws. 

There should be established cheap cooperative 
bakeries among the peasants whereby they may 
protect themselves from dishonest bakers and 
millers. But perhaps a better method might be the 
adoption of some new process of preparing and cook- 
ing corn similar, for example, to that used in 
Mexico {tortilla) and in other countries. 

Treatment should be begun early in all cases, and 
as soon as the first gastric and nervous symptoms 
develop, the patients, if adults, should be given 
arsenous acid, and, if children, sodium chloride. 
In early cases symptoms yield readily to treatment 
and cures become difficult when the case is neglected 
for too long a time. Would it not be in the economic 
interests of the commune to aid in establishing such 
things as small provisional hospitals for early treat- 
ment of these cases, and the consequent prevention 
of hereditary diffusion of the disease? These indi- 
viduals, in this case, with the expenditure of a few 
lire, or even at times a few centesimi, might be 
saved to discharge their duty to society instead of 
perhaps remaining helpless burdens which may ulti- 
mately cost the commune hundreds of lire? It is 
worthy of note also that the Austrian government 
has adopted measures of this kind to aid pellagrins 
in their own homes. 

In some conditions, as after severe inundations, 
for example, when the inhabitants might be forced 
to live on spoiled corn, nothing would remain but to 



PROPHYLAXIS 327 

counsel depopulation of the region by means of 
emigration, if necessary, to other more favored 
places, even to America. 

The sons of pellagrous parents might be sent into 
the army or advised to emigrate to other countries 
which are free from pellagra. 

Finally information with regard to prophylaxis 
and treatment should be disseminated among the 
agricultural classes. Much can be done in this 
manner. (See Appendix IV.) 

Roussel, in his work, formally accepted spoiled 
corn as the cause of pellagra, and was the first to 
spread in France the ideas of Balardini. Later a 
physician of the department of the Hautes Pyre- 
nees, Costallat (1857), became the ardent and con- 
vinced defender of the "verderamist doctrine." 
''Pellagra is a slow poisoning by verderame or 
verdet," said he in reporting the presence of the 
parasite on the corn in the markets of Bagneres-de- 
Bigorre. 

These demonstrations and the different campaigns, 
which popularized them, have succeeded in France. 
The experimental demonstrations have been repeated 
by Balardini, Ellia and others, either with the grain 
of spoiled corn or with polenta made from such 
grain; young chickens fed on it refuse to eat, lose 
weight, become droopy, tremulous, and very thirsty; 
at the end of twenty-eight days they are in the last 
stage of exhaustion and moribund. In Ellia's experi- 
mental chickens the feathers, moreover, became 
roughened and the skin became the site of a fur- 
furaceous desquamation. 



328 PELLAGRA 

Lussana and Frua injected into the veins of dogs 
and of birds, the powder of corn, affected by 
verderame, mixed with water; at one time the 
aqueous extract of this substance ; at another, finally, 
the very fine powder of verderame itself. Most of 
the subsequent symptoms observed, such as dys- 
pepsia, coagulation of the blood, pulmonary 
ecchymoses, vomiting, congestion of the liver, and 
intestinal inflammation could be attributed to the 
severity of the experiments, but not so, the apathy, 
clonic convulsions and paralysis, more or less com- 
plete, especially of the hind legs, which are observed 
in the dogs that, for a time, survive the initial intra- 
venous injections. These phenomena show charac- 
teristics too marked to be misinterpreted. 

Leplat, Jaillard and Lombroso have shown that 
the injection of Penicillium glaucum is harmless, 
provided the injection is so managed as not to pro- 
duce capillary embolism. 

Since then, Grawitz has claimed success in the pro- 
duction of infectious properties in Penicillium 
glaucum and in Aspergillus glaucus by appropriate 
cultural methods. Graffky and, later, Schultz, in 
the laboratory of R. Koch, convinced themselves 
that the foregoing investigator had been deceived. 
Aspergillus fumigatus, A. Flavescens and A. Niger 
are dangerous moulds, but they concern only pul- 
monary mycosis, and not general infections. There 
is also recognized a toxic Mucor stolonifer or Rhizo- 
pus nigricans, which forms the black mould of wheat 
bread. This, also, it would seem, is not to be incrim- 
inated. 






PROPHYLAXIS 329 

Tizzoni, Panichi and Fasoli have isolated and 
cultivated a specific micro-organism common to 
typhoid pellagra, to pellagrous insanity and to 
ordinary chronic pellagra, in different and remote 
localities. They found it in all the principal 
viscera and in the central nervous system; they cul- 
tivated it and injected it into animals, obtaining 
morbid experimental symptoms analogous to those 
of severe pellagra and also nervous and typhoidal 
symptoms. The meninges, the cerebro-spinal fluid 
and the blood in severe cases of pellagra have been 
subjected to culture with success by these authors, 
who describe a specific diplococcus found in the 
viscera, especially the intestines, which enters the 
circulation and through its toxines later involves the 
nervous system. 

[Tizzoni's work has already been discussed in the 
chapter on etiology, q. v.] 

The researches of Lombroso opened a phase 
entirely new in the struggle against pellagra, from 
the all important standpoint of the etiology of this 
scourge. As has been said, the discoveries made by 
Lombroso advance along the same lines as the very 
interesting observations of A. Gautier, Selmi (of 
Bologna), Brouardel and Boutmy, relative to the 
formation and the properties of cadaveric alkaloids 
— the ptomaines. The question here seems to con- 
cern alkaloidal bodies, which, if not ptomaines, are, 
at least, closely allied to them. 

[The nature and origin of these toxines is 
naturally of paramount importance to the Zeist 
idea.] 



330 



PELLAGRA 



Selmi has formally applied to spoiled corn the 
procedure used in the investigation of the ptomaines. 
It is a great honor to Lombroso to have taken up and 
sustained, by experiment, the pregnant idea of his 
illustrious compatriot, Balardini, which others 
blushed to hear called "the Italian doctrine."* The 
assent of Husemann and Cortez, and of Felix (of 
Bucharest) and of the authorities assembled at 
Genoa in 1880, Manassei, Schilling, de Pietra-Santa 
and others, have in large measure compensated the 
Professor of Turin for the rather hasty judgment, 
in 1875, of the Commission of Lombardy Institute. 

Besides corn, other cereals, such as wheat, rye, oats 
and millet, denounced by Faye, are susceptible of 
being invaded by fungi before or after the harvest, 
as Bouchut has remarked. From such cereals intes- 
tinal disturbances may arise which are more or less 
pellagroid in their nature. If corn, which is an exotic 
plant of comparatively recent introduction into 
Europe, and which has not yet acquired the power 
of adapting itself to environment as has wheat, is 
to be grown in various localities, and remain free 
from deleterious change, then it will be necessary to 
find upon our continent conditions of soil and 
climate which approach that of its native land. 
Unless this is done the grain will never arrive at 
perfect maturity, or only arrive at it in a state of 
uncertain vigor, not actually diseased, perhaps, but 
easily subject to general or specific morbid influ- 
ences. It seems, indeed, that everywhere, Mexico 
included, the grain of corn has a delicate germ, 



♦Scientific Congress of Paris, 1867. 



VARIETIES OF CORN 331 

badly protected by its envelop, incessantly menaced 
by dangers and atmospheric influences. Even in Cen- 
tral America there is need of having it properly 
stored, and still it is not eaten until it has been care- 
fully prepared. 

It is probable that it was the object of especial 
care at the time of its transplantation to Europe as 
a rare and valued plant, but since then the farmers 
have strangely relaxed and corn is cultivated on 
all sorts of soil. No attention is paid to the better 
varieties most apt properly to mature, but concern 
is given only to those which give the greatest yield ; 
and advantage is taken of the rapid growth of some 
varieties to sow them even when summer is closing, 
as if corn were not a plant of warm countries. 

The principal varieties of corn cultivated in Italy 
are: 

(a) Summer Corn (zea mays vulgaris aestiva) ; 

(b) Autumn Corn (z. m. autumnalis) ; 

(c) Quarantina Corn (z. m. praecox) ; (40-day 
corn) ; 

(d) Beak Corn (z. m. rostrata) ; 

(e) Cinquantina (z. m. sub-praecox) ; (50-day 
corn) ; 

(f ) Dwarf Corn (z. m. minima) ; 

(g) White Autumn Corn (z. m. autumnalis leu- 
cosperma) ; 

(h) Red Corn (z. m. rubra). 

White corn succeeds in clayey soil, but only the 
yellow variety can be cultivated in sandy soils. 

One of the great advantages of corn for rural 
populations is the fact that certain varieties can 



332 PELLAGRA 

be sown as an after crop in a field which has already 
yielded, in the same year, a harvest of rye or 
legumes; but in this case it cannot be planted until 
the end of June or July. It is necessary, however, 
that it mature early enough to be harvested before 
the bad weather. If it is not cut by the middle of 
September, there is great risk of its being stored 
damp. The grain of the variety called sessanta, 
or "60- day corn," which requires two months for 
maturing, cannot be harvested before the end of 
September, and is almost always stored unripe and 
permeated by dampness. Furthermore, after cutting, 
it does not dry readily upon the ground, because the 
days are short and rainy. The conditions are par- 
ticularly bad when the peasants, induced by the 
large yield, have sown in the mountainous regions 
either this variety, or even the cinquantina (50- 
day corn.) The varieties zea mays aestiva, and z. m. 
autumnalis, which require four to five months for 
maturing, frequently produce crops which have been 
soaked by the rains while ripening in the field. 
These are, however, the preferred kinds, in Umbria, 
for human food, the early varieties being cut green 
for forage. 

The poor system of crop rotation, followed in 
upper Italy, has been censured (Roussel, Lom- 
broso), probably with reason; because corn, like 
every other vegetable growth, loses in quality if it is 
planted on the same ground several times at short 
intervals. The summer and autumn corn occupies 
the land nearly all the season. 






IMPORTED CORN 333 

The unripe and damp grain could, with a little 
effort, be improved and preserved, if it were placed 
in thin piles in dry granaries, and well aired. This 
was formerly done when the cultivation of corn was 
important; but today too much is harvested to give 
the crop the necessary care; it is piled up and 
becomes heated. White corn, very much cultivated 
in Moldavia and Wallachia (Roumania) is particu- 
larly subject to alteration. 

In Italy there is used not only home-raised corn, 
but imported as well. There are merchants in Um- 
bria who sell great quantities of corn brought in 
from Albania, and also from the Danube provinces, 
and Venetia. Some is landed at Ancona, which 
comes from the orient in coasting vessels, especially 
from Albania and also from the Danube provinces. 
Though it is damaged and several years old, trade, 
nevertheless, keeps it going, and it is here that the 
millers come to the aid of the merchants by mixing 
bad meal with good. Lombroso, by concealing his 
identity as expert and philanthropist, easily found 
dozens of samples of rotten corn in the stores of the 
merchants of all the regions of Italy. These grain 
dealers know how to disguise the defects of their 
wares. 

Thus spoiled corn is common in Italy. But who 
eats it, and especially who eats it almost exclusively ? 
Not the farmers in easy circumstances; these eat 
other cereals with the corn, and, furthermore, the 
corn is of good quality; the macaroni of which they 
make soup is made largely of wheat flour. They 
introduce into their diet rice, potatoes, cheese, oil, 



334 PELLAGRA 

fat, sometimes meat, or fish when they dwell near a 
lake or the sea. Many drink wine. It has been 
remarked that the cantons, where formerly wine 
abounded, have become pellagrous since the oidium 
has restricted vine-growing. 

Those who eat scarcely anything but corn, receiv- 
ing it in a spoiled condition during most of the year, 
are the poor laborers of the fields, whose existence is 
at the mercy of the landed proprietor or of the large 
farmer (affitatore) employing them. In Italy the 
landed estates are rarely divided, the land belongs 
to great lords, who usually live in the cities, as in 
England and in Ireland. The land owner rents out 
large tracts to a middle man, who, in turn, sublets 
portions to families of laborers (coloni). Each 
family pays him regularly in kind, in proportion 
to the amount of land they have in charge; he 
employs them, furthermore, at various kinds of 
work at poor wages. This is the system called 
affitanza, the most widely spread in upper Italy, 
and which is oftenest met with in the cantons 
afflicted with pellagra. It is through this system, 
says Senator Jacini, that one realizes the strange 
association of enormous production with the poverty 
of the producing class. Except in especially favor- 
able seasons, when the renter has paid his land rent, 
selling his rye and wheat to pay such rent or to meet 
divers expenses of the family, there remains to him 
only corn enough to last till the next harvest. This 
makes living very hard, as may readily be under- 
stood. Often, towards the end of winter, the renter 
having no corn whatever left, must borrow from the 



AGRICULTURAL METHODS 335 

farmer, who gives him the poorest quality, and for 
this he must return sound grain after the next har- 
vest. The system of mezzadria, or farming on shares, 
is but little better than the preceding. The proprie- 
tor himself divides his land into small portions ; the 
share farmer, who takes one of them, owns at least 
the cattle and farming implements ; he is something 
more than the slave of the ajfitatore. Nevertheless, 
many of the mezzadri are pellagrous; they scarcely 
use more than 1,000 to 1,800 grams of corn per day 
in the form of hard, badly cooked cakes, with vari- 
ous legumes. As for the simple farm hands, it is com- 
mon for corn to be their only daily food, and what 
spoils in the master's cribs falls to their lot. But 
it is necessary to live ! These wretched people know 
in advance what awaits them: 6>, mangiare questa 
minestra! O, saltare questa fenestra/ Cioe andar- 
sene via. [O ! to eat this soup ! O ! to jump out of 
this window ! Either is suicidal !] 

A man named Giardini, according to Lombroso, 
brought dying to the hospital, stammered out: "My 
trouble is rotten polenta!" When cured, he stated 
that he and a dozen hands on the Bisone farm, had 
been fed for six months on corn beaten down in the 
fields by hail; and as the cattle would not eat it, 
men were compelled to do so. 

It is in this way that upon the most fertile land 
of the world, the plains of Lombardy and the valley 
of the Po, an entire class of the people is forced to 
live on produce fit only for the refuse heap. 

Many peasants mix spoiled with good corn, think- 
ing they will be safe because of the good therein. 
Some eat who do not wish to confess it, fearing to be 



22— P. 



336 PELLAGRA 

accused of carelessness in gathering the harvest, or 
of having stolen it from the stalks of the master 
before it ripened (Lombroso). 

When the corn has become toxic, Lombroso says, 
neither parching nor the action of alcohol nor super- 
ficial boiling succeeds in freeing it from its injurious 
properties. To do this would require boiling at 120 
degrees C. with quick lime, then drying in an oven, 
a fact which explains why polenta and corn cakes 
made of spoiled grain remain injurious. 

These two preparations, polenta and cakes, are, 
by far, the commonest forms in which corn is eaten. 
Although corn bread (yellow bread, pane giallo), 
has in it almost always a little rye meal, about one- 
tenth, it is not easily digested on account of its 
compactness, and so all writers condemn it even 
more than polenta or corn mea] gruel. Corn 
enters into the minestra (which is a soup) either in 
the form of meal or in the form of macaroni 
(pasta). 

Formerly in the departments of southwestern 
France, the field hands ate a greater variety of corn 
products, alone or mixed with other things, than 
they do today. The regular preparations were: the 
meture, mesture or mesturet, made in Beam with 
corn meal and water, mixed to a dough, and baked 
in an earthern pan in the oven ; the cruchade of the 
Landes, more often made of millet meal prepared as 
the preceding, but baked in a plate, which renders 
the cake thinner, better baked and more easy to 
digest; the migues or micoles, balls of corn meal 
dough, to be added to pork soup; the broye (in 



CORN PRODUCTS 337 

Beam), touradiso (in Bigorre) or corn dough; the 
hariat, corn dough for soup made with cabbage and 
grease (Lourdes) ; the miliasse and the tougnos 
(Lauraguais), thin corn cakes, with salt and some- 
times with honey. 

At the time of the journey of Eoussel and the 
researches of Costallat, aggravating agricultural 
blunders were seen in the French provinces of the 
southwest, as in upper Italy; the crop rotation 
which every two years permits the replanting of corn 
upon the same field; the cultivation of white corn, 
and of slow growing varieties; the same relations 
between the proprietors and laborers, the share sys- 
tem of farming and the estivandiers (boss-hands) ; 
the most numerous class compelled to eat the 
cheapest food, and, consequently, of the worst qual- 
ity. Indeed, the peasants ate corn so much that they 
had to bring in additional supplies of it from 
Armagnac; and this corn proved to be so much 
damaged that only the very poor ate it, while people 
in easy circumstances fed it to animals (Roussilhe). 
In the Landes, particularly, they usually cultivated 
the variety which is planted in June or July in 
fields which have earlier in the season already 
yielded a crop of rye. 

The mamaliga, which the Wallachian peasants 
regularly eat, is a corn gruel like polenta (Schrei- 
ber). The Roumanians also harvest their corn 
before maturity and pile it in silos where it easily 
ferments. 

Experience shows that the people who eat corn 
perfectly matured, well preserved and protected 



338 PELLAGRA 

from dampness, do so with impunity. It is, there- 
fore, necessary to recommend the varieties which 
rapidly mature, especially quarantina corn. Direc- 
tions should be given for early sowing, and not 
after the previous harvest of some other crop. 
Advice should also be given with regard to diversity 
in crop rotation so as not to permit the planting of 
corn on the same land without an interval of three 
or four years. The topping of the ear to hasten 
maturation complicates the work and probably 
would be neglected or be impossible in cultivation on 
a large scale. Corn harvested before the rainy season 
ought to be dried in the field or the ears hung up 
with open shuck in a high granary, dry and airy, as 
is done in Franche-Comte and in Burgundy. The 
grain ought not to be left in large, but in small piles. 
In Bresse, in Franche-Comte, and in Burgundy, 
says Perrusset, of Macon, after having gathered the 
ears the shuck is drawn back and two piles are made. 
The ears intended for meal, which is to be made into 
cakes, are exposed to the air, suspended by the shuck 
which is left on the stem, under the shade of the 
farm buildings or in the interior of the apartments. 
When the corn is thus well dried, it is shelled for 
grinding. The corn intended for gaurdes, red 
gruel and polenta, is subjected to a kind of drying 
process. Then there is also corn called foumaye 
(dried in the oven), to use the expression of the 
country, and it is made into meal. Meal of corn thus 
dried has a very agreeable odor. It is especially in 
this form that corn is used for food in the previously 
mentioned countries (Roussel). 



CORN PRODUCTS 339 

Thus it is before the formation of verdet that corn 
should be dried and heated naturally or artificially. 
When the moulds are developed, it is too late, since 
the poison, which is now no longer a fungus, resists 
the boiling temperature. This would indeed kill the 
fungi, and, perhaps, their spores; but it does not 
destroy the properties of the alkaloidal bodies, once 
they are formed. The distinction is important and 
it is a precious gleam of light which we owe to Lom- 
broso. 

In southern America, as in Mexico, according to 
Parmentier, care is taken to sun the newly gathered 
ears and put them under cover for the night, and 
never to put them in piles. When they are ready 
for shelling this operation is carried out and the 
grain dried again in the sun. Corn meal does not 
demand less care, being even more easily affected 
than the grain. 

Within the limits of the possible, it is necessary 
to abandon by degrees the practice of using corn 
meal in the form of bread, cakes, cruchade; even 
when mixed with r} T e it is only with difficulty that a 
trustworthy product is obtained in these forms. The 
peasants, unskillful or negligent as they are, obtain 
from it only a food, which is hard, glutinous, indi- 
gestible, and difficult of preservation. The Mex- 
icans avoid eating corn in this state; it is almost 
always gruel (atole) that they make. It is true that 
they have a cake called tortilla, which plays a large 
part in their daily diet; but this is prepared in a 
manner which deserves to be noted. They commence 
by adding to water in a vessel sufficient slaked lime 



340 PELLAGRA 

to make a thick gruel, then corn in full grain is boiled 
in this for eighteen hours. At the end of this 
time the corn is taken out, washed carefully in clean 
water, and afterwards crushed by kneading to make 
a dough which is then formed into cakes. These are 
baked on a hot iron griddle and turned often during 
the baking. Enough gas is formed in the center of 
the dough to cause it to swell and make the bread 
light. 

There is evidently a great moral awakening to be 
wrought among the populations of southeastern 
Europe by general education and instruction in 
dietetics. The prophylactic measures advised for all 
these provinces, by the Commission of Inquiry of 
1879, is: "Amelioration of the condition of the 
peasants, the introduction of meat and wine in their 
dietary." The advice is good, but how shall we 
put it into practice in the present state of land 
ownership in these districts, and under the existing 
agricultural, economic system which the victims 
thereof are unable to reform? The intervention of 
the state with protective measures, by the organiza- 
tion of sanitary surveillance, would perhaps be 
proper. On this delicate ground the question of 
hygiene joins hands with the sociological question. 
Everywhere there should be supervision of the trade 
in food stuffs and the sale of spoiled corn ought to 
be prohibited. Wherever the monotony of living 
on corn alone is broken by the use of some other 
food, which counter-balances its effects, pellagra has 
diminished or disappeared. 



PELLAGRA IN FRANCE 341 

Meat. milk, wine, fish, cheese and even potatoes 
and legumes, these have proven to be potent for 
prophylaxis always when the peasant has been 
able to substitute them more or less completely for 
corn in his daily diet. The importance of favoring 
variety in the cultivation of crops, and of using 
some economical inducement to this end would then 
seem to be indicated. On the other hand we possess 
henceforth in Europe the means of equalizing our 
lack of meat by purchasing, cheaply and in a good 
state of preservation, the surplus of the New World 
and of Australia. 

In France where the division of the landed estates 
permits the peasant to acquire individual ownership, 
pellagra has disappeared, for example, from the 
Landes. How did this happen? They made of a 
marshy waste a rich and fertile country by the 
exploitation of the seacoast pines, and by the cultiva- 
tion of the better cereals, even of the vine, all accom- 
plished by the marvelous works of drainage, which 
are the glory of the government of that region. 
Fever rapidly disappeared, and this is always a bless- 
ing and is moreover an indirect guarantee against 
pellagra. Corn is still cultivated, and is even still 
eaten: but it is, in part, given to the stock; and, if 
it is used for human food, there is added wheat or 
other cereals, legumes, and also meat and wine. The 
peasant of Landes now eats meat several times a 
week, and drinks wine, if not of the first quality, at 
least an alcoholic drink made with malt, raisins and 
corn sugar. A good part of the corn is transformed 
into sugar in several factories. Today the Landes 



342 PELLAGRA 

has railroads, which guarantee the transportation 
and exchange of food stuffs of all sorts. Intelli- 
gence, the will of individuals, the aid of the local 
government, such are, if not the entire prophylaxis 
against pellagra, at least the instruments of this 
great work. "With a little good will on the part of 
the landed proprietors," says Senator Mantegazza, 
"and also of the better class of peasants, it would be 
possible in a half century to abolish pellagra." "Pel- 
lagra ought to disappear and this new disease enter 
into the category of extinct maladies" (J. Arnould). 

ROUSSEL AND LOMBROSO. 

In 1907, a monument to Theophile Roussel was 
unveiled in the Avenue de P Observatoire, and elo- 
quent orators delivered addresses. 

The career of Roussel, the statesman, was recalled, 
also that of the philanthropist, for to him are due 
the laws of the 4th of February, 1873, against drunk- 
enness; those of the 23d of December, 1874, for the 
protection of children and the law in regard to 
delinquent children. He exercised much influence 
over the passage of the law of 1893, upon free med- 
ical aid, as also upon the reports of the senate rela- 
tive to reforming the law of 1838. 

But one fact which nobody recalled — his first 
feat of arms on a field of public charity and hygiene 
■ — was his battle against pellagra. At that date, in 
1845, it was a living question in France; today not 
only the disease, but almost the very name of it, has 
been forgotten, since, thanks to him, its ravages have 
practically ceased. 



ROUSSEL AND LOMBROSO 343 

Roussel recognized that pellagra is "a chronic 
intoxication, characterized, essentially, by a scaly 
erythema limited to those parts most exposed to the 
action of the heat and light, a chronic disturbance 
of the digestive tract, of which the most usual index 
is an obstinate diarrhea, and finally by a lesion, 
more or less severe, of the nervous system, termin- 
ating sometimes in mental alienation and paralysis." 

Roussel contributed his part in showing that 
the cause of this intoxication lies in a food poison 
contained in spoiled corn, and that it affects those 
people who use such products for their food. 

In Europe corn is a relatively recent addition to 
the human dietary, having been imported there 
about 1T00 [?]. Pellagra made its appearance 
soon afterwards, and wherever the cultivation of 
corn as a cereal has extended, pellagra has followed 
in its wake; and has in turn disappeared coinci- 
dently with the abandonment of corn as human 
food, or with the institution of the necessary precau- 
tions against moisture and decomposition of the 
grain, of the meal or of their cooked products. 

At the time when Roussel commenced to sound the 
cry of alarm in France, pellagra in Italy had been 
the subject of special studies by Strambio and by the 
coterie of Italian clinicians who followed him. It is 
known that polenta, made from corn meal, is still 
the principal food in certain parts of Italy and 
Spain; and various national dishes are prepared 
from corn. Accordingly, pellagra makes fearful 
ravages in these countries. Two per cent, of the 
population of certain agricultural districts of Spain 



344 PELLAGRA 

are said to be affected, and in Italy there are still 
(1908) nearly 80,000 pellagrins notwithstanding the 
crusade which Lombroso, following the example of 
Roussell in France, has led against it. 

At last there has sprung from these efforts special 
legislation, which regulates the hygienic condition 
of the granaries and corn transports, the supervision 
of the special markets, the control of foodstuffs of 
this kind, and seeks the suppression of fraudulent 
methods. But numerous congresses and a unity of 
effort on the part of experts and public officials has 
been necessary to repress this evil. 

In France, the Academy of Medicine, stimulated 
by the first work of Roussel, supported his demand 
for a commission to study the matter in Spain and 
in Italy. From this resulted a series of debates and 
finally investigations in the district of Landes, 
the people of which at that time were suffering from 
pellagra. To these circumstances we owe the im- 
portant studies of Roussel on this disease. 

At his visit, in 1844, to the afflicted districts men- 
tioned in the report of Leon Marchand, he found 
conditions somewhat improved, and the disease 
appeared to him to be less serious than had been 
reported. In a general way the disease seemed to 
show some connection with deplorably inferior food, 
and, more especially, with the use of corn which had 
been harvested under conditions favorable to mould- 
ing. 

In Landes, Roussel obtained useful information 
from physicians in active practice, whose names 
should not be forgotten : such are Dejean, Courbin, 



PELLAGRA IN FRANCE 345 

Gazaillan, the two Bergerons, Lemaire (of Mimi- 
zan), Gazaban (of Aurice), Lestelle (of Cauna), 
Comin (of Sos), Dabos and de Calviere (of Gaba- 
ret). It was at Mimizan that Roussel first heard 
popular names of pellagra, some of which have been 
the occasion of much dispute; for example, Mai 
d'Arrouse, de Saint- Amans, de Bascons, de Sainte- 
Rose. The last two are taken from certain places of 
pilgrimage commonly visited by the sick; the name 
mal de Saint- Amans is only a corruption of Saintes- 
Mains, the anointed hands of a certain colossal 
crucifix, from which the pilgrims took salve where- 
with to rub themselves. 

However, in 1847, pellagra was reported by the 
doctors Roussilhe (of Castelnaudary), and Cales (of 
Villefranche) in a second locality in France, not far 
from the first, in the country districts of Laura- 
guais. Roussel used the occasion of his journey to 
verify the facts. Here, without possible error, was 
pellagra again, and, to all appearance, pellagra from 
the poisons of corn. Finally, the departments of 
Hautes and Basses Pyrenees were reported as a third 
disease center; and as Dr. Dozons, of this region, 
had, in 1845, protested against the conclusion of 
Roussel, reached on the very ground where corn is 
cultivated, the learned pellagrologist made a visit 
to his critic in the Pyrenees. It was seen, without 
difficulty, that the quarrymen of Lourdes, who use 
a great deal of corn, but of very good quality, were 
not suffering from pellagra, but certain peasants of 
the neighborhood were victims of it. On the other 
hand, the disease appeared at Cauterets, in the Can- 



346 PELLAGRA 

tons of Nay, of Claraq and of Arudy, and extended 
even into the Canton of Pau (Gros, Pomes, Suber- 
bielle, Fourcade, Darthez, Gazaban, Juppe, Petrique, 
Talamon), always in connection with an extensive 
use of corn, and by reason of the poverty of the 
inhabitants, most often corn of the worst quality. 

Later (1855-1857), in this same region at the foot 
of the Pyrenees, Costallat (of Bagneres), together 
with Verdoux (of Labassere), Duplin (of Laborde), 
Pedebidou, Lacoste (of Ibos), confirmed the diag- 
nosis of pellagra, and showed, by exact facts, its 
connection with the eating of spoiled corn. The 
work of Costallat was the occasion of a report by 
Duplais (1858) to the council of hygiene of the 
Hautes-Pyrenees. The disease, regarded therefore 
as an obscure malady, known only to transalpine 
travelers, was all at once proclaimed as widely 
spread in France. Up to then the people did not 
know how to recognize it, or, perhaps, it was hidden 
under false diagnoses. But the time had come when, 
despite the lack of any real scientific knowledge of 
the matter, the disease was found everywhere, just 
as now is found widely prevalent the typhoid fever 
of Louis, the endocarditis of Bouilland, the disease 
of Bright, the paralysis of Duchenne, etc. Lan- 
douzy, director and professor of the clinical school 
of Rheims, found cases of it, especially in the poor 
houses, a prey to vice and uncleanliness, and to 
physical and moral miseries. The eminent director of 
the clinic himself described the special symptoms of 
the different types and showed to his students not 
only pellagra without direct connection with corn 



ROUSSEL AND LOMBROSO 347 

(hereditary pellagra), but pellagra without poverty, 
pellagra without nervous troubles, typhoid pellagra, 
etc. (Koussel). Under the influence of the same 
movement, Ch. Bouchard also discovered pellagra 
in the Hotel Dieu of Lyons, and in the infirmary of 
the poorhouse of Rhone. Harmon, a pupil of Lan- 
douzy, brought to the attention of the faculty of 
Paris nine cases in sustaining his thesis (1861). 
Bourgade (Clermont-Ferrand) published two cases. 
The physicians of Paris, themselves, found some 
cases of ^sporadic pellagra." 

The Academy of Sciences, in 1865, crowned that 
work of Theophile Roussel, from which a large part 
of this chapter is taken. Landouzy and Bouchard 
have also studied the complex symptoms of this 
poisoning, more and more difficult to find in France, 
now that the cry of alarm sounded by Roussel in the 
middle of the nineteenth century has borne its fruits, 
and the use of the corn as human food has been 
largely abandoned in France. 

The author found in Egypt a situation as lament- 
able as that among the agricultural populations of 
Italy, and of southwest France at the commence- 
ment of the nineteenth century. Roumania and 
southeastern Europe are still poisoned in this way, 
and will be for a long time. The recent uprising of 
the Roumanian peasants is directly associated with 
their wretchedness in which pellagrous poisoning 
plays no small part. 

Regis, at Bordeaux, and Mairet at Montpellier, 
have recently (1008) made an investigation which 
concludes the series of studies on pellagra in France, 



348 PELLAGRA 

for it shows that pellagra has lived its day, and that 
there remains only the vestiges of hereditary taint 
manifested by mental troubles, erythemas, etc., 
occurring in a generation who have never eaten corn, 
but whose parents were poisoned by it. 

The asylums of Auch, of Montpellier and of Pau 
contain still some survivors of the terrible pellagrous 
insanity, which Eoussel has, so to speak, dried up 
at its sources, by announcing its cause ; and, with the 
assistance of the medical corps of these regions, by 
influencing the people to give up this food product. 
The industrial improvement among the people has 
completed the work of liberating France from the use 
of a cereal now abandoned to animals. Let us hope 
that the vine growers' crisis and its miseries will not 
replunge the south of France into these distresses. 

The writer believes that it is not without interest 
that he has recalled this page in the life history of a 
good man, who has, among other merits, the glory of 
having so completely delivered his country from this 
scourge that even before his death the people had 
almost lost the memory of it. 

Less happy than France, in this respect, Italy 
still suffers from the terrible scourge of pellagra, 
though having blazed out the way leading to an 
unwearied scientific crusade. At the head of the 
present movement we must recognize Professor 
Cesare Lombroso, from whom we have borrowed the 
essential points for the writing of this book, which 
is but a feeble reflection of the enormous labor of a 
long life. For Lombroso consecrated a large part of 
his life to the fight against this cause of degenera- 



ROUSSEL AND LOMBROSO 349 

tion so prevalent in his beautiful native country. 
More tried than France by international disturb- 
ances of war, followed by internal crises, Italy, in 
the course of the miseries of the century, has 
especially suffered from pellagrous poisoning. Like 
all the social poisons, this has been a disease of 
poverty closely dovetailed with the social evils from 
which she is freeing herself by degrees. As did 
Roussel for France, so in Italy, Lombroso has shown 
how to direct successfully the work of social redemp- 
tion. If it is less complete, it is because the disease 
was deeper seated than with us; and if France was 
the first to free herself, this was due to the cry of 
alarm in Italy, whose echo Roussel caught and 
resounded in his own country. To Italy and her 
scientific leaders public acknowledgment is due. To 
Lombroso, particularly, the illustrious philanthrop- 
ist and master, who has kindly permitted me to epi- 
tomize his great work, the writer owes this acknowl- 
edgment. 



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1799 

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1817 

Holland, H. : Pellagra in Lombardy. Med. Chir. Tr., Lond., 
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1820 

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1826-7 
The Pellagra. Lancet, Lond., 1826-7, XI, 476-478. 

1831 

Johnson, J. : Change of Air in Pursuit of Health. An Excursion 
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1835 

Rayer : Pellagra. In his : Theoret. and Pract. Treatise on Dis. 
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1845 

Kerr, W. : Pellagra : Cycl. Pract. Med. (Tweedie) Phila., 1845, 
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1846 

Clymer, M. : Remarks on Pellagra. Med. Exam., Phila., 1846, 
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23— P. 



352 PELLAGRA 



1852 

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1859 

Copland, J. : Pellagra. In his : Diet, of Pract. Med. ; Ed. by 
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1859-60 

Billod, E. : Abstract of a paper by, on a variety of pellagra 
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1863 

DeWolff, J. : A Short Note on Some Cases of Pellagra (erytheme 
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Wilks, S. : Case of Pellagra. Assoc. M. J., Lond., 1863, 114. 

1864 

Gray, J. P. : Case of Pellagra of the Insane. Am. J. Insan., 
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1866 

Howden, J. C. : A Case of Pellagra Occurring in the Montrose 
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1874 

Bucknill, J. C, and Tuke, D. H. : Pellagrous Insanity. In 
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1876 

Fox, T., and Farquhar, T. : Pellagra. In their: On Certain 
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1881 

The Pellagra in Italy. Edin. Rev., April, 1881. 



BIBLIOGRAPHY 353 



1882 

Sherwell, S. : Report on a Case of Pellagra. J. Cutan. and 
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1884 

Wilson, E. : Pellagra. Quain's Diet, of Med., 7th Ed., 1884, p. 
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1885 

Creighton, C. : Article on Pellagra. In : Encyclopedia Britannica, 
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1887 

Pons Sanz, A. : Pellagra in Badajoz. Lancet, 1887, Oct. 22, 825. 
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1892. ffl 

Tuczek, F. : Pellagra. In Tuke's Diet. Psycholog. med. Vol. II, 
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1893 

Tuczek, F. : Pellagra. From his : Monographie sur la pellagre, 
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1895 

Kaposi, M. : Pellagra. In his : Pathology and Treatment of 
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1897 

Allbutt, T. C. : Grain Poisoning — Pellagra. In his : Syst. of 
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Sandwith, F. M. : Pellagra in Egypt. Brit. J. Dermat, Lond., 
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1898, II, 881. 

1899 

Anon : Grave Increase of Pellagra. Lancet, Lond., 1899, II, 
1134. 



354 PELLAGRA 



1901 

Sandwith, F. M. : Three Fatal Cases of Pellagra, with Examina- 
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1900-01, VII, 460-464. 

: Pellagra. In : Encyclop. Med., 1901. Also reprint. 

1902 

Harris, H. F. : Anchylostomiasis in an Individual Presenting all 
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Ray, U. : The Pellagrous Affections of the Skin in North Behar. 
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Scheube, B. : Pellagra in his Dis. of Warm Countries. Lond. & 
N. Y., 1902. 

Sherwell, S. : A Note Relative to a Case of Pellagra (Abstract). 
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Tuczek, F. : Pellagra. In : D. H. Tuke's Diet, of Psycholog. Med., 
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Warnock, J. : Some Cases of Pellagrous Insanity. J. Ment. Sc. 
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1903 

Corlett, W. T. : Pellagra. In : Reference Handb. of Med. Sc. 
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Radcliffe-Crocker, H. : Pellagra. In his : Dis. of the Skin. 
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Sandwith, F. M. : How to Prevent the Spread of Pellagra in 
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1904 

Stelwagon, H. W. : Pellagra. In his : Treatise on Dis. of the 
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1905 

Sambon, L. W. : Remarks on the Geographical Distribution and 
Etiology of Pellagra. Brit. M. J., Lond., 1905, II, 1272-1275. 
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1905, p. 281. 

1906 

Allbutt, T. C, and Rolleston, N. D. : Pellagra. In their : 
System of Med., Lond., 1906, II, 892-97. 

Bianchi, L. : Pellagrous Insanity. In his : Text-Book of Psy- 
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BIBLIOGRAPHY 355 



Brown, A. C. : Pellagra Occurring in England. Practitioner, 
Lond., 1906, LXXVI, 679-685. 

rellagra near Milan. Lancet, Lond., 1906, I, 1431. 

1907 

Babcock, J. W., and others: What are Pellagra and Pellagrous 
Insanity? Does Such a Disease^ Exist in South Carolina, and 
What are its Causes? An Inquiry and Preliminary Report. Rep. 
Bd. Health South Carolina, 1907, Columbia, 1908, 60-78. Reprint. 
Also : J. South Car. Med. Ass., Greenville, 1908, IV, 64-76. Also : 
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Harris, H. F. : Pellagra. Rep. Georgia St. Bd. Health, 1907, 
IV, Atlanta, 1908. 

Merrill, T. C. : A Sporadic Case Diagnosed as Pellagra. J. Am. 
Med. Ass., Chicago, 1907, XLIX, 940. 

Manson, Sir P. : Pellagra. In his : Tropical Diseases, 4th Ed., 
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Health, Aug., 1909, 325-333. 

Roberts, W. E. : A Tennessee Case of Pellagra. Am. J. Clin. M., 
Chicago, 1907, XVI, 1348. 

Searcy, G. H. : An Epidemic of Acute Pellagra. Tr. M. Ass. 
Alabama, Montgomery, 1907, 387-393. Also : J. Am. M. Ass., Chi- 
cago, 1907, XLIX, 37. 

Wood, E. J. : A Mixed Infection with Tertian and Quartan 
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Am. M. Ass., Chicago, 1907, XLIX, 1891-1895. Also: Reprint. 

1908 

Bellamy, R. H. : Pellagra ; its occurrence in this country ; Report 
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Card, W. R. : Report of Two Cases of Pellagra. Trans. Miss. 
State Med. Assoc, 1908. 

Conference on Pellagra, held under the Auspices of the State 
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Insane, Oct. 29, 1908. 8 vo., Columbia, S. C, 1909, 59 pp. Ann. 
Rep. So. Car. State Bd. of Health, 1908, XXIX, 123-180. Also 
reprint. 

Papers : 

•Moore, N. M. : Etiology of Pellagra. 

♦Wood, E. J. : Pellagra — Some Problems in the Study of its 
Etiology. 

•Watson, J. J. : Etiology of Pellagra. The Italian Maize 
Theory, or the Theory of Lombroso. 

•Thompson, J. L. : The Roumanian Theory as to the Cause of 
Pellagra. 

•Taylor, J. H. : The Protozoan Theory of Pellagra. Also : 
Reprint. 

•McCampbell, J. : A Theory as to the Cause of the Recent 
Appearance in This Country of Pellagra. 

•Taylor, I. M. : Personal Experience with Some Cases of 
Nervous and Mental Diseases Showing the Pellagra Syndrome. 



356 PELLAGRA. 



♦McConnell, H. E. : Clinical Observations on Pellagra. 

Frontis, D. B. : Report of Three Cases of Pellagra in One 
Family. 

♦Neuffer, G. A. : Four Cases of Pellagra. 

Lancaster, R. A. : A Case of Pellagra. 

Powers, M. R. : The Supposed Relationship of Damaged Grain 
to Epizootic Cerebro-Spinal Meningitis of Horses (Blind Staggers). 

♦Griffin, H. H. : The Pathology of Pellagra. 

♦Whaley, E. M. : Report on the Examination of the Eyes in 
Eighteen Cases of Pellagra. 

*Babcock, J. W. : The Diagnosis and Treatment of Pellagra. 



♦Printed also in Jour, of South Carolina Medical Association, 
Nov., 1908. 

Cutting, W. Bayard, Jr. : Pellagra in Italy. Unpublished Con- 
sular Report to Asst. Sec. of State from Milan, Italy, Nov. 2, 1908. 

Ferrero, G. : Lombroso, Prophet and Criminologist. Century 
Magazine, LXXVI, 6, 925, N. Y., 1908. 

Harris, H. F. : Pellagra. Trans. Med. Assoc, of Ga., 1908. 

King, J. M. : Pellagra, with Report of Cases. South. M. J., 
Nashville, 1908, I, 289-293. 

Lavinder, C. H. : Pellagra, a Pr6cis. Pub. Health Rep. U. S. 
Pub. Health and Mar. Hosp. Service, Wash., 1908. Also : Reprint, 
22 pp. 1 PI. 

Leach, S. : A Case of Pellagra. Tr. M. Ass. Alabama, Mont- 
gomery, 1908, 446-452. 

Lee, L. and Cross, E. S. : Pellagra — a report of two cases. 
Trans. Med. Assoc, of Ga., 1908. 

McCampbell, J. : Some Observations on Pellagra in This Coun- 
try, with Special Reference to Pellagrous Insanity. Charlotte 
(N. C.) M. J., 1908, LVIII, 83-86. 

Moore, N. M. : Pellagra : Report of Case with Remarks on 
Etiology. J. Am. M. Ass., Chicago, 1908, LI, 1076. 

Pellagra in South Carolina. (Editorial) J. Am. M. Ass., Chi- 
cago, 1908, L, 450. 

Sandwith, F. M. : Pellagra. In : Green's Encyclop. and Diet, of 
Med. and Surg., Edinb. and Lond., 1908, VII, 374-378. 

Stoddart, W. H. B. : Pellagra and Pseudo-Pellagra. In his : 
Mind and Its Disorders. 8 vo., London, 1908, 430-431. 

Symposium on Pellagra at Meeting of North Car. Med. Soc, 
June 16-18, 1908. Trans. N. C. Med. Soc, 1908. 

Papers : 

Wood, E. J. : Symptoms and Diagnosis of Pellagra. 

McCampbell, J. : Observations on Pellagra. 

Lavinder, C. H. : Etiology and Pathology of Pellagra, 

Discussion of above papers. 

Wood, E. J. : The Appearance of Pellagra in the United States. 
Tr. Coll. Phys., Phila., 1908, 3 S., XXX, 196-224. 2 PI. Also: 
J. Am. M. Ass., Chicago, 1909, LIII, 274-282. 



BIBLIOGRAPHY 357 



1908-9 

Randolph, J. H. Notes on Pellagra and Pellagrins, with 
Report of Cases. Arch. Int. Med., Chicago, 1908 9, II, 553-568. 
1 PI. Also: Mobile M. and S. J., 1909, XIV, 65-87. Also: J. 
South, M. Ass., Shreveport, 1909, VI, 305-330. Also : Reprint. 

Rudolph. C. M. : Pellagra. Alabama M. J., Birmingham, 1908-9, 
XXI, 283-291. 

Searcy, G. H. : Pellagra in the Southern States. N. Orl. M. 
and S. J., 1908-9, LXI, 413-423. 4 Pi. 

1909 

Allen, W. : Amebae in the Stools of Pellagrins. N. York M. J., 
etc., 1909, XC, 1212. 

Alsberg, C. L. : The Relation of the Production and Utilization 
of Maize to Pellagra. Symposium at Meeting of the Am. Soc. of 
Trop. Med., 1909. 

: Agricultural Aspects of the Pellagra Problem in 

the United States. N. York M. J., etc., 1909, XC, 50-54. Also: 
Reprints. 

Aulde, J. : Pellagra ; an Inquiry. N. Y. M. J., etc., 1909, XC, 
1142-1144. 

B , W. A. : Pellagra. South. M. J., Nashville, 1909, 

II, 857. 

Bailey, E. B. : Report of Fifteen Cases of Pellagra. J. Am. M. 
Ass., Chicago, 1909, LIII, 2159. 

Bass, C. C. : Complement Fixation with Lecithin as Antigen in 
Pellagra. Prelim. Note. J. Am. M. Ass., Chicago, 1909, LIII, 
1187. Also : N. Y. M. J., etc., 1909, XC, 1,000. 

Bondurant, E. D. : Pellagra, with Report of Eight Cases. Tr. 
Am. Neurological Ass., May, 1909. Also : Woman's M. J., Cincin., 
1909, XIX, 183-187. Also : Med. Rec, N. Y, 1909, LXXVI, 300-304. 

Brown, R. D., and Low, R. C. : Pellagra. Edinb. M. J., 1909, 

III, 197-202. 

Bryan, : Pellagra as Observed at the South Atlantic 

and Cape Fear Quarantine Stations. Pub. Health Report U. S. 
Pub. Health and Mar. Hosp. Serv., Wash., 1909, XXIV, 1489. 

Carter, M. H. : Pellagra, the Medical Mystery of Today. Mc- 
Clure's Mag., N. Y., 1909, XXXIV, 94-104. 

Clarke, A. B. : Diseases of the Eye in Pellagra. Med. Rec, N. 
Y., 1909, LXXVI, 1032. 

Cole, H. P. : The Transfusion of Blood as a Therapeutic Agent, 
with Report of Transfusion in a Case of Pellagra. South. M. J., 
Nashville, 1909, II, 631-638. Also : Reprint. 

: Transfusion of Blood in a Case of Pellagra. J. 

Am. M. Ass., Chicago, 1909, LII, 633. 

Conference (National) on Pellagra, held under the Auspices of 
South Carolina State Board of Health at State Hospital for the 
Insane, Columbia, S. C, Nov. 3 and 4, 1909. In : Ann. Rep. St. 



358 PELLAGRA 



Bd. Health of South Car., 1909, XXX, 124-419. Also Reprint. 

Papers : 

Sandwith, F. M. : Introductory Remarks, 136-141. 

Kerr, J. W. : Pellagra as a National Health Problem, 142-146. 

Watson, E. J. : Economic Factors of the Pellagra Problem in 
South Carolina, 147-154. Also : Reprint. 

Lavinder, C. H. : Notes on the Hematology of Pellagra, 155-162. 
Discussion on papers of Drs. Kerr and Lavinder, 162-167. 

Zeller, G. A. : Pellagra. Its Recognition in Illinois and the 
Measures Taken to Control It, 168-174. 

Siler, J. F., and Nichols, H. J. : Aspects of the Pellagra Problem 
in Illinois. Part I. A Statistical Study of 100 Cases at the 
Peoria State Hospital (J. F. Siler). Part II. Notes on the 
Epidemiology of Pellagra (H. J. Nichols), 175-186. Discussion 
on the papers of Drs. Zeller, Siler and Nichols, 186-197. 

Dyer, I. : Some Differential Points in the Skin Lesions of 
Pellagra : Report of a Case with Removal of Svmptoms, 198-207. 

Harris, H. F. : Pathology of Pellagra, 208-215. 

Rohrer, C. W. G. : Pellagra: Its Etiology, Pathology, Diag- 
nosis and Treatment, 216-222. 

Gaumer, G. F. : Pellagra in Yucatan, 223-229. 

Williams, D. J. : Pellagra in Jamaica, 230-231. 

Manning, C. G. : Psilosis Pigmentosa in Barbados, 232-236. 

Marie, A. : Pellagrous Insanity Among the Arabs in Egypt, 

Warnock, John : Pellagra in Egypt, pp. 241-242. 

White, R. G. : Pellagra in Egypt, 243-247. 

Saunders, Eleanora B. : The Gynecological, Obstetrical and 
Surgical Aspects of Pellagra ; a Preliminary Study, 248-258. 

Mobley, J. W. : Pellagra ; Its Relation to Insanity and Certain 
Nervous Diseases, 259-269. 

Discussion of the paper of Dr. Mobley, 270-271. 

Bass, C, C. : Complement Fixation with Lecithin as Antigen in 
Pellagra — Further Observations, 272-273. 

Fox, H. : The Wassermann Reaction (Noguchi modification) in 
Pellagra : Report of Thirty Cases, 274-279. Also : N. Y. Med. 
J., Dec. 18, 1909. Also: Reprint. 

Cole, H. P., and Winthrop, G. J. : Transfusion in Pellagra, 
280-291. 

Discussion of the papers of Drs. Bass, Fox and Cole. 291-292. 

King, J. M. : Report of Pellagra at Nashville, Tenn., 293-300. 

Discussion on paper of Dr. King, 300-302. 

Taylor, J. H. : The Question of the Etiology of Pellagra, BOB- 
SIS. 

Discussion on Daper of Dr. Taylor, 313-320. 

Whaley, J. S. : Personal Experience with Damaged Corn, 321- 
323 

McConnell, H. E. : Some Facts and Theories of Pellagra, 324- 
328. 

Watson, J. J. : Symptomatology of Pellagra and Report of Cases, 
329-340, 4 PI. 

Allen, W. : Amebae in the Stools of Pellagrins, 341-343. Dis- 
cussion, 343. 

Nisbet, W. O. : Results of Stomach Analyses in Pellagra, 344- 
346. 

Bailey, T. W. L. : Personal Observations on Pellagra, 347-349. 

Randolph, J. H., and Green, R. N. : Further Observations on 
Pellagra with Points on Prognosis, 350-356. 

Parker, R. : Clinical Observations of Four Cases of Pellagra, 
357-364. 

Buchanan, J. M. : Pellagra at East Mississippi Insane Hospital, 
365-370. 






BIBLIOGRAPHY 



359 



Miller, J. R. : Report of a Case of "Pellagra Universalis," 371- 
374. 

Lunner, J. : Report of a Sporadic Case of Pellagra, 375-376. 

Maddox. T. : Report of Eight Cases of Pellagra, 377-382. 

Griffin. H. H. : Is Pellagra Communicable, or Hereditary ? 383- 
388. 

Discussion on the paper of Dr. Griffin, 388. 

Young, M. B. : Pellagra in Children, 389-392. 

Torrence, C. : A Case of Labor in a Pellagrin, with Subsequent 
History of Mother and Child, 393-396. 

Clarke, A. B. : Diseases of the Eye in Pellagra, 397-400. 

Whaley, E. M. : Eye Symptoms of Pellagra, 401-405. 

Drewry, W. F. : Comments on Twenty-one Cases of Pellagra, 
406-409. 

DeJarnette, J. S. : Pellagra, the Corn Curse, 410-415. 

Mitchell, G. W. : A Case of Pellagra in Illinois, Occurring Out- 
side of an Institution, 416-419. 

Conference on Pellagra in Columbia, S. C, 1909. (Editorial) 
J. Am. M. Ass., Chicago, 1909, LIII, 1645. 

Conference on Pellagra . . . under Auspices S. C. State Bd. 
Health at State Hosp. for Insane, Columbia, S. C, Nov. 3-4, 1909. 
Account of in : J. Am. M. Ass., Chicago, 1909, LIII, 1659-1670. 

Dock, G. : The Importance of Recognizing Mild Cases of Pel- 
lagra. Southern M. J., Nashville, 1909, II. 

Dyer, I. : Some Differential Points in the Skin Lesions of Pel- 
lagra : Report of a Case with Removal of Symptoms. N. Y. M. J., 
etc., 1909, XC, 997-999. 

Edwards, A. R. : Pellagra. In his : Treatise on the Principles 
and Practice of Med., N. Y„ and Philadelphia, 1909, 2d Ed., 1187. 

Egan, J. A. : Pellagra in Illinois. Bull. 111. State Bd. of Health, 
Aug., 1909, 279, 306, Illus. 

Elmer, W. P. : Pellagra and Pellagrins. St. Louis M. Rev., 
1909, LVIII, 123. 

Eskridge, F. L. : Clinical Features and Diagnosis of Pellagra, 
with Remarks on Treatment. Med. Brief, St. Louis, 1909, XXXVII, 
680-683. 

Goldwaite, H. : Reports Fifty-three Deaths from Pellagra Among 
Colored Patients of the Alabama State Hospital for the Insane. 
Pub. Health Report U. S. Pub. Health and Mar. Hosp. Serv., 
Wash., 1909, XXII, 801. 

Guiteras, J. : Pellagra. San. y Benefic. Bol. Oflcial., Habana, 1909, 
II, 373-376 [English transl.] 377-379. 

Hewitt, J. H. : Pellagra in Virginia. J. Am. M. Ass., Chicago, 
1909, LIII, 1085-1087. 

Henderson, R. G. : Pellagra, with Report of Case and Presenta- 
tion of Patient. Memphis M. Month., 1909, XXIX, 510-514. 

Hyde, J. N. : Pellagra. In his : Dis. of the Skin. N. Y., 1909, 
8th Ed., p. 1069-1072. 

King, H. D. : Pellagra, Ancient and Modern. J. Am. M. Ass., 
Chicago, 1909, LIII, 1556-1559. 

King, J. M. : Pellagra. South. Med. J., Nashville, 1909, II, 857. 

Kirk, C. D. R. : Pellagra. Eclect. M. J., Cincin., 1909, LXIX, 
538. 



360 PELLAGRA 



Lancaster, E. H. : Report of Bulletin of Texas State Board of 
Health on Other Texas Cases [of Pellagra], Texas M. News, 
Austin, 1909, XIX, 153-156. 

Lavinder, C. H. : Etiology of Pellagra. N. York M. J., etc., 
1909, XC, 56-58. Also : J. So. Car. M. Assoc, Greenville, 1909, V, 
355. Also : Reprint. 

: The Prophylaxis of Pellagra. South. M. J., Nash- 
ville, 1909, II, 1118-1123. Also: Pub. Health Rep. U. S. Pub. 
Health and Mar. Hosp. Serv., Wash., 1909, XXIV, 1617-1624. Also : 
Reprint. 

: Pellagra. Pub. Health Rep. U. S. Pub. Health and 

Mar. Hosp. Serv., Wash., 1909, XXIV, 1703. 

: Notes on the Prognosis and Treatment of 

Pellagra. Pub. Health Report U. S. Pub. Health and Mar. Hosp. 
Serv., Wash., 1909, XXIV, 1315-1321. Also : Reprint. 

: Etiology of Pellagra : Discussion. Symposium 

at Meeting of the Am. Soc. of Trop. Med., 1909. 

: The National Conference on Pellagra held at 

Columbia, S. C, Nov. 3 and 4, 1909. Pub. Health Rep. of U. S. 
Pub. Health and Mar. Hosp. Serv., Wash., 1909, XXIV, 1697-1702. 

: Pellagra in the State Hospital for the Insane at 

Peoria, 111. Pub. Health Rep. U. S. Mar. Hosp. Serv., Wash., 
1909, XXIV, 1362. 

: The Etiology of Pellagra. N. York M. J., 

Peoria, 111. Pub. Health Rep. U. S. Pub. Health and Mar. Hosp. 
Serv., Wash., 1909, XXIV, 1362. 

, Williams, C. F., and Babcock, J. W. : The 

Prevalence of Pellagra in the United States : A Statistical and 
Geographical Note with Bibliography. Pub. Health Rep. U. S. 
Pub. Health and Mar. Hosp. Serv., Wash., 1909, XXIV, No. 25, 849- 
852. Also : J. South Car. Med. Ass., Greenville, 1909, V, 351. 
Also : Reprint, 8 vo., Washington, 1909. Also in : Trans. Am. 
Med.-Psycholog. Assoc, 1909, 283-285. Discussion. Also : Reprint. 

McCafferty, E. L. : Pellagra among the Colored Insane at the 
Mt. Vernon Hospital. Gulf States J. M. and S., etc., Mobile, 1909, 
XIV, 228-236. 

Minor, T. C. : Pellagra. Lancet-Clinic, Cincin., 1909, CII, 
309-311. 

Moore, N. M. : Prevalence of Pellagra in the United States. 
Symposium at meeting of the Am. Soc. of Trop. Med., 1909. 

Moorer, M. P. : Pellagra. Report from Georgetown, S. C. Pub. 
Health Rep., U. S. Pub. Health and Mar. Hosp. Serv., Wash., 1909, 
XXIV, 1531. 

National Conference on Pellagra. See Conference (National) on 
Pellagra, in this list. 

Nisbet, W. O. : Results of Stomach Analysis in Pellagra. Char- 
lotte (N. C.) M. J., 1909, LX, 365. 

Osier, W. : Pellagra. In his : Principles and Pract. of Med., 
N. Y. and London, 7th Ed., 1909, 384. 



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361 



Pellagra. Ann. Rep. U. S. P. H. & M.-H. Service, Wash., 1909, 
XXIV, 1576. 

Pellagra and Pellagrins. (Editorial) Charlotte M. J., 1909, LX, 
243. 

Pellagra. (Editorial) South. M. J., Nashville, 1909, II, 461. 

Pellagra. (Editorial) South. M. J., Nashville, 1909, II, 974. 

Pellagra. (Editorial and illustrations) Illinois M. J., Chicago. 
1909. XVI, 4, 440. 

Pellagra. (Editorial) J. Am. M. Ass., Chicago, 1909, LII, 1106. 

Pellagra in Austria. (News item) J. Am. M. Ass., Chicago, 1909, 
LOT, 808. 

Pellagra in Austria. (Vienna Corresp.) Lancet, Lond., 1909, 
I, 1641. 

Pellagra in Nashville. (News item) Memphis Med. Month., 
1909, XXIX, 446. 

Pellagra in Shetland. J. Trop. Med. and Hyg., Lond., 1909, 
IV, 316. 

Pellagra in the United States. (Corresp. letter) Lancet, Lond., 
1909, I, 1082. And II, 1691 (Editor.) 

Pellagra. Important Topic of Physicians ; Scientists Gather at 
Columbia, S. C, for Conference. Texas Med. News, Austin, 1909, 
XIX, 163-167. 

Pellagra in Illinois. Monthly Bulletin 111. State Board of 
Health, Springfield, Aug., 1909. 

Pellagra. Italian Congress. (Editorial) J. Am. M. Ass., Chi- 
cago, 1909, LIII, 1405. 

Pellagra: The Latest Medical Peril. (Edit.) Am. J. Clin. M., 
Chicago, 1909, XVI, 1345-1348. 

Pixley, C. S. : Some Clinical Studies on Pellagra. Charlotte 
(N. C.) M. J., 1909, LX, 368-373. Also: Reprint. 

Pollock, L. J. : Pellagra : Its Appearance in the Cook County 
Institutions. J. Am. M. Ass., Chicago, 1909, LII, 1087-1091. . 

Rudolph, C. M. : Pellagra ; Honor to Whom Honor is Due. Ala. 
M. J., Anniston, 1909, XXI, 544. 

Saunders, C. H. : Tellagra ; Report of a Case. Virginia M. Semi- 
Month., Richmond, 1909-10, XIV, 299. 

Saunders, E. B. : The Gynecological, Obstetrical and Surgical 
Aspects of Pellagra. Am. J. of Insanity. 

S , C. M. : A Suspicious Case; Was it Pellagra? Am. J. 

Clin. M., Chicago, 1909, XVI, 1350. 

Sheel, W. T. : Two Cases of Pellagra? J. Am. M. Asso., Chi- 
cago, 1909, LIII, 2005. 

Shoemaker, J. V. : Pellagra. In his : Pract. Treatise on Dis. of 
the Skin. 8 vo., Phila., 1909, 5th Ed., 747-751. 

Siler, J. F. : Some Observations on Pellagra at the Peoria State 
Hosp., Bull. 111. State Bd. of Health, Aug., 1909, p. 315, 320. Illus. 

Smith, E., and Hedges, Florence : Diplodia Disease of Maize. 



362 PELLAGRA 



(Suspected Cause of Pellagra). Science, N. Y., 1909, July 9 f 
XXX, 60-61. 

Symposium at Meeting of the Am. Soc. of Tropical Med., 1909. 

Papers : 

Moore, N. M. : Prevalence of Pellagra in the U. S. 

Alsberg, C. L. : The Relation of the Production and Utilization of 
Maize to Pellagra. 

Lavinder, C. H. : Etiology of Pellagra. — Discussion. 

Tanzi, E. : Pellagra. In his : Text-Book of Mental Diseases. 
Transl. from the Italian by W. Ford Robertson and T. C. Mackenzie. 
8 vo., London, 1909, 286-308. 

Taylor, J. H. : The Question of the Etiology of Pellagra. N. Y. 
Med. J. XC, 1909, 1208-1212. Also : reprint. 

Thayer, W. S. : Note on Pellagra in Maryland (2 cases). Johns 
Hopkins Hosp. Bull., Bait, 1909, XX, 193-200. 2 PI. Also: 
South. Pract., Nashville, 1909, XXXI, 357-378. 

Townsend, A. M. : Pellagra ; Its History and Symptomatology. 
J. Nat. M. Ass., Tuskegee, Ala., 1909, I, 88-91. 

Treatment of Pellagra. (Edit.) Lancet, Lond., 1909, II, 1364-5. 

Treatment of Pellagra by Polymineralized Radio-Actire Solution. 
(Edit.) Boston M. and S. J., 1909, CLXI, 520. 

Turner, J. S. : Pellagra : Texas M. News, Austin, 1909, XIX, 
141-152. 

Walker, N. P. : Clinical Features of So-Called Acute Pellagra. 
J. Am. M. Ass., Chicago, 1909, LIII, 15. Also: South. Pract, 
Nashville, 1909, XXXI, 378-382. 

Warfield, L. M. : Notes on Pellagra. Interstate M. J., St. Louis, 
1909, XVI, 819-824. 

Watson, J. J.: Pellagra. N. York M. J., etc., 1909, LXXXIX, 
936. Also: Reprint. 

Welton, C. B. : Eye Symptoms of Pellagra ; Preliminary Report 
of Examination of Eyes of Fifty-five Patients. J. Am. M. Ass., 
Chicago, 1909, LIII, 1636. 

Whaley, E. M. : The Ocular Symptoms in Pellagra. Ophth. 
Rec, Chicago, 1909, XVIII, 510-513. 

Williamson, O. L. : Pellagra in Arkansas. J. Am. M. Ass., 
Chicago, 1909, LIII, 717. 

Wolff, B. : The Skin Lesions of Pellagra. Am. J. Dermat. and 
Genito-Urin. Dis., St. Louis, 1909, XIII, 343-346. 

Wollenberg, R. A. C. : Pellagra in Italy. Pub. Health Rep. U. S. 
Pub. Health and Mar. Hosp. Serv., Wash., 1909, XXIV, No. 30, 
July 23. 

: Statistics and the Law with Reference to the 

Disease (Pellagra) in Italy. Texas Med. News, Austin, 1909, 
XIX, 221. 

Wood, E. J. : Present Status of the Pellagra Problem. Char- 
lotte (N. C.) M. J., 1909, LX, 69-73. 

: Pellagra. Abstr. from: J. Am. M. Ass., Chicago, 

July 24, 1909. South. M. J., Nashville, 1909, II, 979-980. 



BIBLIOGRAPHY 363 



: "Pellagra sine Pellagra," with a Differential 

Diagnosis from Sprue. Trans. Tri-State Med. Assoc, 11th Vol., 
446. 

Wood, E. J., and Bellamy, R. H. : Pellagra. Bull. North Car. 
Bd. Health, Raleigh, 1909, XXIV, 83-91. 

Wood, G. W. : Pellagra : Perhaps. Am. J. Clin. M., Chicago, 
1909, XVI, 1348. 

Zeller, G. A. : Pellagra ; Its Recognition in Illinois and the Steps 
Taken to Control the Disease. Bull. 111. State Bd. of Health, Aug., 
1909, pp. 307; 314. Illus. 

1909-1910 

Bass, C. C. : Pellagra ; a Report of Eleven Cases from Missis- 
sippi ; Presentation of a Case. N. Orl. M. and S. J., 1909-10, 
LXII, 177-182. 

: A Case of Pellagra Caused by Amylophagy Result- 
ing from Uncinariasis. Nashville J. M. & S., CIV, 308-310. 

Cross, E. S., and Lee, L. : Pellagra ; a Report of Two Cases. 
Atlanta Jour.-Rec. Med., 1909-10, XII, 191-202. 

Daspit, H. : Some Blood Findings in Twenty Cases of Pellagra 
in the Insane Asylum of the State of Louisiana. N. Orl. M. & S. J., 
1909-10, LXII, 716, 1 ch. 

DeJarnette, J. S. : Pellagra ; the Corn Curse. Virginia M. Semi- 
Month., Richmond, 1909-10, XIV, 366-369. 

Dorsey, R. T. : Etiology of Pellagra. Atlanta Jour.-Rec. Med., 
1909-10, XII, 401-406. 

Drewry, W. F. : Pellagra ; a Clinical Study and Report of Four- 
teen Cases. Virginia M. Semi-Monthly, Richmond, 1909-10, XIV, 
265 ; 300 ; 326. Also : Texas M. News, Austin, 1909, XIX, 156-162. 
Also : Reprint. 

Eiker, B. L. : Pellagra ; Notes Taken from the National Confer- 
ence on Pellagra, held at Columbia, S. C. Iowa Med. J., etc., Des 
Moines, 1909-10, XVI, 287. 

Hummel, E. M. : Two Cases of Pellagra. N. Orl. M. and S. J., 
1909-10, LXII, 434-438. 2 PI. Discussion, 469-471. 

Jarrell, W. W. : Report of a Case of Pellagra in Metcalf, Ga. 
Atlanta Jour.-Rec. Med., 1909-10, XII, 464. 

Kerr, J. W. : Pellagra as a National Health Problem. Louisville 
Month. J. M. and S., 1909-10, XVI, 225-228. 

Lavinder, C. H. : Notes on the Hematology of Pellagra. Read 
before the Conf. on Pellagra, Columbia, S. C, Nov., 1909. Virg. Med. 
Eeml-Month., Richmond, 1909-10, XIV, 465. 

Newman, E. D. : A Case of Pellagra in New Jersey. J. Med. Soc. 
N. J., Orange, 1909-10, VI, 606-608. 

Parker, R. : Pellagra and Clinical Observations of Two Cases. 
Virginia M. Semi-Month., Richmond, 1909-10, XIV, 341-345. 

Phenix, N. J. : Pellagra in Colorado, Texas. Texas State J. M., 
Fort Worth, 1909-10, V, 276. 

Rohrer, C. W. G. : Pellagra ; Its Etiology, Pathology, Diagnosis 



364 PELLAGRA 



and Treatment. Virginia M. Semi-Month., Richmond, 1909-10, XIV, 
417-421. 

Saunders, C. H. : Pellagra : Report of a Case. Virginia M. Semi- 
Month., Richmond, 1909-10, XIV, 299. 

Schultze, F. P. : Pellagra : Report of a Case. Iowa M. J., etc., 
Des Moines, 1909-10, XVI, 289. 

Slack, H. R. : Pellagra, with Report of Cases. Atlanta Jour.-Rec. 
Med., 1909-10, XII, 343-350. 

, and McCall, W. R. : Pellagra : Report of Cases 

with Treatment. Old Dominion J. M. and S., Richmond, 1909-10, 
IX, 317-323. 

. Thomas, J. N. : Report of [.Three] Cases of Pellagra at State 
Asylum, Pineville, La. N. Orl. M. and S. J., 1909-10, LXII, 35-40. 
2 PI. Also : Reprint. 

Thrash, E. C. : Symptomatology of Pellagra. Atlanta Journal- 
Rec. Med., 1909-10, XII, 425-428. 

Townsend, A. M. : Pellagra. J. Nat. Med. Ass., Tuskegee, Ala., 
1910, II, 65-70. 

Transactions of National Conference on Pellagra, held under 
auspices of So. Car. State Brd. Health at St. Hosp. f. the Insane, 
Columbia, S. C, Nov. 3rd and 4th, 1909, 8vo., 297 pp. Columbia, 
S. C, 1910. See Conference (National) for papers read. (In this 
list). 

Unique (A) Experience with Pellagra. Am. J. Insan., Bait., 
1909-10, LXVI, 711-714. 

Vanderhoof, D. : Pellagra in Virginia ; Report of a Case. Old 
Dominion J. M. and S., Richmond, 1909-10, IX, 324-328. 

Van Wart, R. M. : Report of a Case of Pellagra. N. Orl. M. and 
S. J., 1909-10, LXII, 244-249. Discussion, 280-282. 

1910 

Allison, B. and Allison, W. : Pellagra ; with Report of Cases. Med. 
Fortnightly, St. Louis, 1910, XXXVIII, 285-290. 

Alsberg, C. L. and Black : The Determination of Deterioration 
of Maize with Special Reference to Pellagra. Bull. Dept. of Agri- 
culture, Wash., 1910. 

Anderson, P. V. : Personal Experiences with a Few Cases of Pel- 
lagra. Med. Rec, N. M., 1910, LXXVII, 531-535. 

Anderson, W. : Pellagra, or Maidismus. Elect. M. Gleaner. N. S. 
VI, 4, 277, 1910. 

Babcock, J. W. : The Pellagra Problem, Past and Present. N. 
York M. J., etc., 1910, XCI, 44-46. 

: The Prevalence and Psychology of Pellagra. 

Trans. Am. Med.-Psych. Assoc, 1910. Also in Jour. S. C. Med. 
Assoc, Sept. and Oct., 1910. Also : Reprints. 

Bacon, J. H. ; A Case of Pellagra in Illinois. J. Am. Med. 
Assoc. Chicago, 1910, LIV, 1783. 



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Bass, C. C. : The Early Symptoms of Pellagra. Interstate M. J., 
St. Louis, 1910, XVII, 175-178. 

: Climatic Treatment of Pellagra. A Preliminary 

Report. Jour. Am. Med. Assoc. LV, 11, 940. 

Bone, R. L. : Pellagra, with Exhibition of Case. Kentucky M. J., 
1910, VIII, 1673. 

Blue, R. : Pellagra in California. Calif. State J. of Med., San 
Fran., 1910, VIII, 101. 

Bowen, J. T., and Towle, H. P. : Progress in Dermatology ; Pel- 
lagra. Boston M. and S. J., 1910, CLXII, 605-612. 

Cantlie, J.: Pellagra Investigating Committee (British). Pros- 
pectus, March 1, 1910. 

Castellani, A., and Chalmers, A. J. : Pellagra. In their : Manual 
of Tropical Medicine. Lond. and N. Y., 1910. 906-911. 

Cole, H. P., and Winthrop, G. J. : Pellagra ; Transfusion In 
Eleven Cases. J. Am. M. Ass., Chicago, 1910, LIV, 1354-1356. 

Cooper, G. R. : Pellagra. Eclectic M. J., Cincin., 1910, LXXI, 12. 

Corlett, W. T. : A Case of Pellagra. Trans. Am. Dermatolog. 
Assoc, 1910. 

Dearborn. F. M. : Pellagra and Its Recent Manifestations. Hahne- 
mann Month., Phila., 1910, XLV, 250-257. 

Delcourt, A. J., Sr. : Pellagra. J. Am. M. Ass., Chicago, 1910, 
LIV, 1121. 

Drewry, W. F. : Some Observations on Pellagra. 8° Richmond, 
1910. Rept. from Old Dominion J. M. and S. Richmond, 1910, X. 

Eiker, B. L. : Pellagra. Bull. Iowa State Institutions, 1910, 
XII, 2, 104. 

Eason, J. S. : Report of a Case ; Possibly Pellagra. J. Am. M. 
Ass., Chicago, 1910, LIV, 792. 

Fitzgerald, Clara P. : A Case of Pellagra in Massachusetts. 
J. Cutan. Dis. incl. Syphilis, N. Y, 1910, XXVIII, 42-46, 2 PI. 

Fox, Howard : Personal Observations on the Skin Lesions of 
Pellagra. Med. Record, X. Y., Feb. 5th, 1910. Also : Reprint. 

: A Case of Pellagra. N. Y Med. J., Feb. 26, 

1910. Also: Reprint. 

Gaumer, G. F., and Gaumer, G. J. : Pellagra in Yucatan. Am. 
M. J., St. Louis, 1910, XXXVIII, 89-101. Also in: Ellingwood's 
Therapeutist, & in Eciect. Med. Gleaner, N. S. VI, 4, 263, 1910. 

Gottheil, W. S. : Pellagra. Progressive Med., Sept., 1910, 117. 

Green, A. F. : Pellagra ; Gnat Causes Pellagra. Eciect. M. J. 
Cincin. 1910, VIII, 387-391. 

Hyde, J. N. : Pellagra and Some of Its Problems. Am. J. M. 
Sc, Phila., 1910. N. S. CXXXIX, 1-26. 3 PI. Also : Reprint. 

Jelks, J. L. Amebiasis : Complicated in One Instance by Pellagra. 
J. Tenn. M. Ass., Nashville, 1910, III, 94-106. 

King, J. M. : The Treatment of Pellagra. Internat. Clin., Phila., 
1910, 20 S., I, 58-61. 2 PI. 

: Report, with Illustrations, of Pellagra at Nash- 
ville, Tenn. Gulf States J. M. & S., etc., Mobile, 1910, XVI, 
277-292. 4 PI. 



366 PELLAGRA 



King, H. D. : The Etiologic Controversy Regarding Pellagra. 
J. Am. M. Ass., Chicago, 1910, LIV, 859-866. 

Lavinder, C. H. : On the Prophylaxis of Pellagra. Lancet-Clinic, 
Cincin., 1910, CIII, 234. 

: Pellagra. 111. Med. J., Springfield, 1910, XVII, 48. 

: The Theory of the Parasitic Origin of Pellagra. 

Pub. Health Rep. U. S. Pub. Health and Mar. Hosp. Serv., Wash- 
ington, 1910, XXV, 735-737. 

Lockwood, W. F., Beck, H. G., and Rohrer, C. W. G. : Clinical 
Hist, and Path, of Pellagra. Med. and Chir. Fac. of Md., Apl. 
26-28, 1910. Jour. A. M. A. LIV, 21, 1720. 

Lockwood, W. F. : Clinical Notes on Four Cases of Pellagra. 
Old Dominion J. M. and S., 1910, X, 414-417. 

Long, J. D. : Pellagra. Jour. Am. Med. Assoc, LV, 9, 734, 1910. 
Discussion. Also : Reprint. 

MacNeal, W. J. : Pellagra. Illinois M. J., Springfield, 1910, 
XVII, 59-67. 

Marie, A. : Pellagra. Trans, by Lavinder, C. H., and Babcock, 
J. W., Columbia, S. C. The State Co., 1910. 

Merriwether, F. T. : Pellagra. Charlotte (N. C.) M. J., 1910, 
LXI, 231-233. 

Miles, G. W. : Some Remarks on the Treatment of Pellagra. 
Med. Rec. N. Y., 1910, LXXVIII, 448. 

Nichols, H. J. : Hook-worm Disease and Pellagra. Military Sur- 
geon, Wash., 1910, XXVI, 646-657. 

Norris, H. : Treatment of a Case of Pellagra by Appendicostomy. 
Prelim. Rept. Charlotte, N. C, M. J., 1910, LXII, 1-3. 

Pegram, R. W. S. : Pellagra. Charlotte, N. C, M. J., 1910, 
LXII, 100. 

Pellagra (The) Field Commission. (Editorial) Brit. M. J. Lond., 
1910, I, 1255. 

Perry, M. L. : Two Cases of Pellagra in Kansas. Trans. Am. 
Med. Psych. Assoc, 1910. 

Pittman, H. M. : Pellagra in Perryville, Kentucky, M. J. Bowling 
Green, 1910, VIII, 1739. 

Reed, H. S. : The Fungus, Diplodia, as a Possible Factor in the 
Aetiology of Pellagra. N. Y. M. J., etc, 1910, XCI, 164-169. 

Robertson, J. W. : Pellagra, an Abstract. Hosp. Bull. Univ. 
Maryland, Bait, 1910, VI, 29. 

Rohrer, C. W. G. : The Pathology of Pellagra. Maryland M. J. 
Bait., 1910, Mil, 298-300. 

Rudolph, C. M. : Clinical Types of Pellagra. Alabama M. J., Bir- 
mingham, 1910-11, XXIII, 142-145. 

Russel, C. K. : Pellagra. Article in : Osier's Modern Med., 
Phila. and New*York, 1910, VII, 139-141. 

Sage, D. N. : Pellagra. Atlanta Jour.-Rec Med., 1910-11, LVI, 
20-28. 

Sambon, L. W. : Progress Report on the Investigation of Pellagra. 
Jour. Trop. Med. and Hygiene, 1910, XIII, 18, 27. Also : No. 19. 






BIBLIOGRAPHY 367 



Scott, W. B. : A Case of Pellagra. North West Med. II, 9 N. S., 
282. 

Siler, J. F., and Nichols, H. J. : The Pellagra Problem, Past and 
Present. Med. Times, Lond., 1910, XXXVIII, 120; 139; 160; 188. 

and : Observations on Pellagra at the 

Peoria State Hospital, Peoria, 111. Med. Rec, N. Y., 1910, 
LXXVII, 87-98. 

Silver, D. R. : Corn and Pellagra : a Contribution to Our Knowl- 
edge of Their Relation as Probable Cause and Effect. J. Am. M. 
Ass., Chicago, 1910, LIV, 452. Also : Reprint. 
South Carolina Commercial Feed Stuffs Act, Act of the General 
Assembly, Session of 1910, Columbia, S. C. 

: Rules and Regulations Governing the Sale of 

Commercial Feed Stuffs in the State of S. C, as provided for in 
Sections 11 & 12 of "An Act to Regulate the Sale of Commercial 
Feed Stuffs," etc. Columbia, S. C, 1910. 

: Rules and Regulations Governing the Inspec- 
tion and Sale of Agricultural Seeds sold in the State of South 
Carolina, as provided for in "An Act Regulating the Sale of and 
Providing for an Inspection of Agricultural Seeds sold in the State 
of S. C. and to provide Penalties for Violations," approved Feb. 
26, 1910. Columbia, S. C. 

Symposium on Pellagra. Trans. Florida Med. Assoc, 1918. 

Papers : 

Randolph, J. H. : The Nervous and Mental Symptoms of Pellagra, 
and What Can be Done for Them? 

Winthrop, G. J., and Cole, H. P. : The Value of Transfusion in 
Pellagra. 

Turck, R. C. : Pellagra Complicating a Laparotomy. 

Stern, Samuel : Pellagra in Philadelphia. 

Tappan, J. W. : Photographs of a Case of Pellagra. Bull. El 
Paso Co. 11 Soc, El Paso, Texas, 1910, II, No. 3. 

Trask, J. W. : Pellagra. Detroit M. J., 1910, X, 227-230. 

Tucker, B. G, : Pellagra ; Its Treatment. Read at Ann. Conf. of 
State & County Health Officers, Nashville, Apr. 6, 1910. South. 
Pract.. Nashville, 1910, XXXII, 222-226. 

Warren, F. B. : Pellagrins — Newest Disease Victims. Illust. 
Tech. World Mag., Jan., 1910, XII, 5, 509. 

Warthin, A. S. : Report of a Case of Pellagra, with Post Mortem 
Findings. Physician and Surg., Detroit and Ann Arbor, 1910, 
XXXII, 17-21. 

Watson, J. J. : The Symptomatology, Pathology and Treatment 
of Pellagra. N. York M. J., etc., 1910, XCI, 46-48. 

: Symptomatology of Pellagra. Internat. Clin., 

Phlla., 1910, 20 S., I, 42-57, 2 PI. Also : Reprint. 

: Symptoms of Pellagra. Lancet Clinic, Men. 5, 

1910. 

Waugh, W. F. : A Case of Pellagra in Illinois. Med. Rec. N. Y., 
1910, LXXVIII, 191. 
24— P. 



368 



PELLAGRA 



: Pellagra In Illinois. Chicago M. Times, 1910, 

XLIII, 273-278. 

Webster, G. W. : Pellagra with Special Reference to Etiology 
and Diagnosis. Illinois M. J., Springfield, 1910, XVIII, 139-151. 

Wolfe, J. J. : Pellagra ; the Causative Agent and the Method of 
Infection. South Atlantic Quarterly, 1910, IX, 43. 

Zeller, G. A. : Pellagra : Some Clinical and other Features of 
the Disease, Interstate Med. Jour., XVII, 10, 745. Illust. 



1910-11 
Report of a Case. 



West. Va. Med. Jour., 



Bloss, J. R. : Pellagra. 
1910-11, V, 13-16. 

Lavinder, C. H. : Report of a trip to Italy investigating pellagra, 
with reference to its origin, spread and control. Ann. Rept. of the 
Surgeon General of the U. S. P. H. and M.-H. Service for the 
fiscal year 1910. Wash. 1911. 

Winthrop, G. J. and Cole, H. P. : The Value of Transfusion in 
Pellagra. N. Ore. M. and S. J., 1910-11, LXIII, 90-97. 



B. FOREIGN BIBLIOGRAPHY. 

CHRONOLOGICAL AND ALPHABETICAL.* 

1740 

Feijoo : Lettre a Casal sur le "mal de la Rosa" dans la Galice, 
1740. See Roussel : De la pellagre, p. 277. 

1755 

Thiery : Description d'une maladie appelSe "le mal de la 
Rosa." Recueil p6riodique d'observations de m6decine, de chirur- 
gie et de pharmacie, juin, 1755, Paris, 2d Ed., 1783. 

1762 

Casal, Gaspar : Historia natural y medica de el principado de 
Asturias. Obra p6stuma que escribid (1735) el Doct. D. Gaspar 
Casal, medico de Su Magestad y su Protoni6dico de Castilla, Acad- 
gmico de la Real Academia Medica Matritense &c, sacada a luz por 
el Doct. Juan Joseph Garcia Sevillano. En Madrid, Ano de 1762. 
P. 327, § III. "De affectione quae vulgo in hac regione 'mal de la 
Rosa' nuncupatur." 



Frapolli, Fr. 
Milan, 1771. 



1771 
Animadversiones in morbum vulg& pelagram. 



1776 

Fanzago, F. L. : D'una specie particolare di Scorbuto. Venezia, 
In : Nuova Raccolla di opuscoli scelli sulle scienze e sulle arti, t, III, 
p. 217, Milan, 1780. 

Odoardi, J. : D'una spezie particolare di scorbuto. Belluno, 1776. 
1776. In : Sulla pellagra memoria di F. L. Fanzago, I, II, Padua, 
1815. 

1780 

Gherardini, M. : Descrizione della pellagra. Milan, 1780. 



•The foreign bibliography of pellagra is very extensive, especi- 
ally the Itnlian. It has, therefore, been decided to include here 
only the leading articles upon the subject in other languages. The 
reader is referred to the Index Catalof/ue of the Library of the Sur- 
geon Goneral's Office, United States Army, Vol. X, first series, and 
Vol. XII. second series, and to the more recent volumes of the 
Index Medicus. For older literature see also Hirsch II, p. 171. The 
literature up to 1887 has been carefully compiled by Salveraglio, 
q. v. in this list. 



370 PELLAGRA 



1781 

Albera, G. M. : Trattato teor. prat, della malattia dell' insolato 
di primavera volgarmente detto pellagra. Varese, 1781. 

1786 

Strambio, Gaet. : De pellagra observationes in regio pellagro- 
sorum nosocomio factae ; ann. 1-5. Milan, 1786-1789. 

— : Due dissertazioni sulla pellagra, t. II. Milan, 1794. 

1788 

Jansen, F. X. : De pellagra morbo in Mediol. ducatu endemico. 
Lugduni (Leyde), 1788. Also in: Delect, opusc, by P. Franck, t. r 
I. Ticini, 1790. 

1789 

Fanzago, Francesco-Luigi : Mem. sopra la pellagra. Padua, 1789. 

: Paralleli tralla pellagra ed alcune malattie. 

Padua, 1792. 

: Memoria sulla pellagra. Padua, 1815. 

Soler, L. : Osservazioni med. prat., che formano la storia esatta 
di una particolare malattia, cbimata pellagra. Venice, 1791. 

1791 

Bona, Paul D. : Discorso comparative sopra la pellagra, l'ele- 
fantiasi dei Greci e lepra degli Arabi e lo scorbuto. Venice, 1791. 

1792 

Thiery : Observation sur une maladie end^mique des Asturies en 
Espagne, qu'on appelle "mal de la Rosa." M6d. eclairee, Paris, 
1792, IV, 78-81. 

1795 
Allioni, C. : Raggionamento sulla pellagra. Turin, 1795. 

1805 

Le Vacher de la Feutrie : Recherches sur la maladie endSmique 
dans le Milanais. Paris, 1805. 

1807 
Cerri, G. : Trattato della Pellagra. Milan, 1807. 

1810 
Marzari, J. B. : Saggio med. politico sulla pellagra o scorbuto 



BIBLIOGRAPHY 



371 



italiano. Venice, 1S10. 

: Delia pellagra e della maniera di estirparla in 

Italia. Venice, 1819. 

1811 
Boerio, Ant. : Storia della pellagra nel Carnovese. Turin, 1811. 

1814 

Chiarugi, V. : Saggio di ricerche sulla pellagra. Florence, 1814. 

1818 

Zecchinelli, G. M. : Alcune refl. sanit polit. sullo stato attuale 
della pellagra nelle due provincie di Belluno e di Padova con- 
frontato collo stato in cui era in addietro. Padua, 1818. 

1829 

Hameau, : Une maladie peu connue observed [en 1818] 

dans les environs de la Teste. Soc. Roy. de M6d. de Bordeaux, 4, 
mai, 1829. Also : Journal d. M6d. de Bordeaux, 1829. Also : Bull, 
de I" Acad, de M6d., 1832, II, 7. 

: Description d'une maladie nouvelle, observed 

sur le littoral du bassin d'Arcachon. Bull. Acad, de M6d., Paris, 
1837-38, II, 6. 

1830 

Briere de Boismont : MSmoire sur la meiiingo-enc£phalite pella- 
greuse en Italie. 1830. 

: De la pellagre et de la folie pellagreuse. Paris, 

1834. 

: Recherches sur les rapports de la pellagre 



avec l'alienation mentale. Ann. m6d.-psych., 1866, VIII, p. 161. 



1831 

Liberal!, S. : Sulla condizione, etc. Sur la nature inflammatoire 
de la manie pellagreuse et de la pellagre en g6n€ral. Milan, 1831. 

: Sulla condizione, etc. Sur la nature inflammatoire 

de la pellagre et son extension a l'axe cerebrospinal, prouvee par 
les autopsies cadav€riques et les observations cliniques. Venice, 
1839. 

1832 



Spessa, Andr. Aug. : Sulla pellagra. 
d'Omodei, 1832, t, LXIV, p. 207. 



In : Annali univ. di med. 



1836 
• Lalesque, F. A. : De la pellagre des Landes. 
Paris, 1836-[7], I, 440. 



Bull. Acad, de m6d. 



372 PELLAGRA 



1844 

Ahmed ibn Hassan el Rahshidy el hakeem : El Roda el bahiya fee 
mudawat el amrad el glldyeh. Bulak, 1844, vol. I. 

1845 

Balardini, L. : Delia pellagra, del granoturco, quale causa precl- 
pua di quella malattia e dei mezzi per arrestarla. Milan, 1845. 

Roussel, T. : Etiologie de la Pellagre. Gaz. meU de Par., 1845, 
2 S., XIII, 820. 

: De la pellagre, de son origlne, de ses progres, de 

son existence en France, de ses causes et de son traitement curatif 
et prGservatif. Paris, 1845. 

: Trait6 de la pellagre et des pseudo-pellagres. 

Ouvrage couronne* par l'lnstitut de France (Academie des sciences.) 
Paris, 1866. 

1847 

Articles in Annales medico-psychologiques. Ire Serie, IX-X, 1847, 
et seq. 

Calderini, : Votigia med. statistiche sulla pellagra. Milan, 

1847. 

Pruner : Topographie mGdicale du Caire. Munich, 1847, 

p. 67. 

1849 

Baillarger, O. : Lettre 316. Ann. MeU Psych., I-XII, 1849. 
Verga : Delia pellagra e della paralisi generale degli alienati. 
Gaz. med. Lomb., 1849. 

1853 
Hameau, J. M. G. : De la pellagre. Paris, 1853. 

1855 

Billod, E. : D'une endemie de pellagre, etc., dans les asiles. Ann. 
meU Psych., Par., 1855, p. 595. 

: D'une endemie de pellagre observee dans les asiles 

d'Hle-et-Vilaine et de Maine-et-Loire. Bull, de 1'Acad. de M6decine, 
5 juillet, 1855. Also see under date 1870. 

1860. 

Landouzy, : De la pellagre sporadique. Paris, 1860. 

1862 

Bouchard, C. : Recherches nouvelles sur la pellagre. Paris, 1862. 

: Etude d'anatomie pathologique sur un cas de 

pellagre, etc., Compt. Rend. Soc. de biol. Par. 1864, 4 S. I., 51-56. 
Also : Gaz. Med. de Par. 1864, 3. s., XIX, 599-600. 



BIBLIOGRAPHY 373 

1866 

Laurens : Etiologle et traitement de la pellagre. Paris, 1866. 

1868 

Lombroso, C. : Sulla pellagra maniaca e sua cura. Gior. ltal. d. 
mal. ven., Milan, 1868, I, 31 ; 83 ; 137. 

: Studil clinici ed sperimentali sulla natura, causa e 

terapia della pellagra. Riv. clin. dl. Bologna, 1869, VIII, 289 ; 321 : 
1870, IX, 126; 215; 242; 269; 298; 368. 2 PI. Also: Reprint. 
Also: Atti. . . .r. 1st. Lomb. di sc. e lett., Milano, 1870, V, nt. 2, 
1-174. 

: Sintomatologia della pellagra. R. Inst. Lomb., di 

sc. e lett. Rendic, Milan, 1869, 2 S. II, 1213-16. 

: Studi statistic! sulla pellagra in Italia. Rendi- 

conti del Reale Instituto Lombard., 1872, V, Nos. 15, 16. 

: Sulle cause della pellagra. Gaz. med. Lomb., 1872, 

Nos. 27, 29, 44. 

: Sull' etiologia della pellagra. Gaz. med. Lomb., 

1873. No. 39, p. 385. 

: Le sostanze tossiche del maiz guasto. Gaz. med. 

Lomb., 1875, No. 38. 

: Sulle sostanze tossiche (sticniche) del maiz 

guasto. Riv. clin. di Bologna, 1875, Dec. p. 368. 

: I veleni del maiz alia loro applicazione all' 

Igiene ed alia terapia. Riv. clin. di Bologna, 1878, Jan., p. 8 ; 
Apl., p. 103 ; July, p. 211. 

: Rettifica di priorita sull* anatomia patologica 

della pellagra. Riv. clin. di Bologna, 1800, Sept. 

: Trattato profilattico e clinico della pellagra. 

Turin, 1892. 

: Sull' etiologia e sulla cura della pellagra. Lavorl 

d. cong. di med. int., 1892, Milan, 1893, V, 160-186. 

: Die Lehre von der Pellagra. Deutsch hsgg. von 

Hans Kurella, Berlin, 1898. 

: Molino Bamford Rapid a mano nella profilassl 

della pellagra. Arch, di psichiat, etc., Turin, 1908, XXIX, 
139-142. 

1870 

Billod, E. : Traite" de la pellagre, 1870. 
1871 

Manzlni, G. B. e Dotti, T. : Dell' arsenlco nella cura della pella- 
gra e della pazzia. Gaz. med. Lomb., 1871, No. 9. 

Gemma, A. M. : Sull' arsenico nella cura della pellagra. Ann. 
univ. di med., 1871, March, p. 564. 

: La pellagra del lattantl e del Bambini. Gaz. med 

Lomb., 1871, Nos. 44, 45, 50. 



374 PELLAGRA 



: Delle dermopatie pellagrose. Ann. univ. di med., 

1871, July, p. 31. 

: Dei morbi pellagrici delle vie mucose. Ann. 

univ. di med., 1872, June, p. 451. 

: II fatto clinico dei ritmi pellagrici non fu 

spiegato colla teorica maizitica. Gaz. med. Lomb., 1872, No. 45. 

: Contributo all' etiologia della pellagra. Gaz. 

med. Lomb., 1873, No. 18, p. 138 ; No. 19, p. 145 ; No. 38, p. 299. 

— : Nosografia e terapia della pellagra. Ann. univ. 

di med., 1873, July, p. 1 ; Aug., p. 249. 

: Sull' etiologia della pellagra. Gaz. med. Lomb., 

1874, Nos. 7, 8 ; 1875, Nos. 5, 6. 

Strambio, G. : Intorno alia cura della pellagra. Gaz. med. Lomb., 

1871, Nos. 3, 5. 

Balardini, L. : Progressi della questione della pellagra dopo 
l'anno 1855 in Italia ed in Francia, etc. Ann. univ. di med., 1871, 
July, p. 70. 

1872 

Balardini, L. : Sulla causa della pellagra. Gaz. med. Lomb., 

1872, No. 24. 

: Contributo all' etiologia della pellagra. Gaz. 

med. Lomb., 1873, No. 24, p. 125. 

Lussana, F. : Sulle cause della pellagra. Gaz. med. Lomb., 1872, 
Nos. 9, 13, 16, 18, 19, 21. 

: Sull' azione della cosi della sostanza tossica 

del maiz guasto e della cosi dell' olio rosso ed ossidato. Gaz. med. 
Lomb., 1875, No. 33, p. 257. 

e Ciotto : Sugli alcaloidi del maiz guasto. Gaz. 

med. Lomb., 1884, Nos. 9-14, 16-18, 24-29. 

1873 

Bellini : Contributo sull' etiologia della pellagra. Gaz. med. 
Lomb., 1873, No. 26, p. 201. 

1874 

Bellini, L. : Contributo sull' etiologia della pellagra. In : Gazz. 
Lo sperimentale, agosto, 1874, p. 186. 

: Nuove osservazioni di osteomi dell' aracnoide 

spinale nei paralitici, 1877. 

Tamburini, A. : Le trasfusioni del sangue nella pellagra. In : 
med. Lombard., Nos. 7, 8 ; 1874. 

1875 

Biffl, S. : SuU' azione dell' olio di maiz guasto. Rel. d. com. d. 
R. 1st. Lomb. d. sci. e let. per esam. e rif. intorno ai result, d. 
prof. C. Lombroso. Gaz. med. Ital. Lomb., 1875, Nos. 21, 22. 



BIBLIOGRAPHY 



375 



1876 

Tizzoni, Guido : Sperienze cliniche e fisiologiche coll' olio e 
tintura di maiz guasto. In : Rivista clinica di Bologna, Agosto, 
18T6. 

Winternitz, W. : Eine klinische Studie uber die Pellagra. 
Vrtljschr. f. Derm., 1876, No. 2, p. 151 ; No. 3, p. 387. 

1877 

Bouchard, M. : Experiences relatives a la production de l'erytheme 
solaire et plus particulierement de l'erytheme pellagreux. Gaz. 
meU de Paris, 1877, No. 23, p. 284. 



1879 

Bonfigli, C. : Sulla pellagra. II Raccogl. med., 1879, Jan. 30, 
Apl. 10. 

Maragliano, D. : Studi statistic! sulla diffusione della pellagra in 
Italia, etc. Giorn. della Soc. d' ig., 1879, I, Nos. 2, 3. 

1880 

Bennati, : Sui pellagrosi curati nell' acrispedale di S. Anna 

in Ferrara. II raccogl. med., 1880, Dec. 10. 

Fua, : Observations sur le role attribue' au mais, employe 
comme aliment, dans la production de la pellagre. Compt. rend., 
Acad. d. Sc, Par. 1880, XCI, 866-867, 1880, No. 21. 

La Pellagra in Italia. Rome, 1880 (official report, with appen- 
dices relating to France, Spain and Roumania, etc.) 

1881 

Dejgrine, J. : Sur les alterations des nerfs cutangs dans la pel- 
lagre. Compt. rend., Acad. d. Sc, Par. XCIII, 1881, No. 2. 

Sepilli, G. : Ricerche sul sangue dei pazzi pellagrosi. Gaz. med. 
Ital.-Lomb., 1881, No. 43. 

1882 

Antoniu, : 'Etiologie pellagreuse. Borladu, 1882. 

1883 

Hirsch, A. : Handb. der hist.-geogr. Path., 1883, 2d Ed., II, p. 
150. 

Tonnini, S. : I disturb! spinali nei pazzi pellagrosi. Riv. sperim. 
dl Reggio, 1883, IX, No. 1, p. 118 : Nos. 2-3, p. 208 ; X, 1884, p. 63. 

1887 

Neusser, E. : Untersuchungen tiber die Pellagra. WIen. med. 
Woch., 1887, No. 5, p. 132. 

: Pellagra in Oesterreich u. Rumiinien. Wien. med. 

Pr., 1887, No. 4, p. 146. 



376 PELLAGRA 



Salveraglio : Bibliografia della pellagra. Milan, 1887. 
Verga : Pellagra. In : Enciclopedia medica italiana. Milan, 
1887. 

1888 

Baillarger, : Analogies des symptSmes de la paralysie pella- 

greuse et de la paralysie generate. Ann. M6d-psych., Par., 1888, 
7. s. VII, 194-214. 

Tuczek, F. : Ueber die nervosen Storungen bei der Pellagra. 
Deutch. med. Woch, Leipz., 1888. XIV, 222-225. Also : Reprint. 

: Klinische u. anatomische Studien fiber die Pellagra. 

8vo., Berlin, 1893. 

: Behandlung des Ergotismus, der pellagra und des 

Lathyrismus. Handb. d. spec. Therap. innerer Krankh., Jena, 1894, 
II, 373-392. Also : Handb. d. Therap. innerer Krankh., 2. Aufl., 
Jena, 1897, II, 618-635. 

: Ueber die nervosen Erscheinungen der Pellagra. 

Verhandl. d. Gesellsch. deutsch. Naturf. u. Aerzte., 1905. Leipzig, 
1906, 283-300. 

1889 

Belmondo, E. : Le alterazioni anatomiche del midollo spinale 
nella pellagra, e loro rapporto coi fatti clinici. Riv. sper. di 
freniat., Reggio-Emilia, 1889, XV, 266 ; 394. 1890, XVI, 107, 1 pi. 
Also : Labstr.] Riforma med., Napoli., 1889, V, 1532-1534. 

Bonnet :La pellagre chez les alien es. Ann. m€d.-psych., Par., 
1889, 7 s. IX, 372-406. 

Paltauf u. Heider: Der Bacillus maidis (Cuboni) und seine 
Beziehungen zur Pellagra. Vienna, 1889. 

Raymond, Paul : Les alterations cutanges de la pellagre. Ann. 
de Dermat. et de Syph. Par., 1889, 2 &., X, 627-636. 

1890 

Berger, L. : Pellagra. Wiener Klinik, 1890, XVI, 161-179. 

De Giaxa, : Pellagra : Manuale d'igiene pubblica. 8vo. Milano, 
1890-92, pp. 1156-1166. 

Strambio, Gaetano, Jr. : La Pellagra, i pellagrologi e l'Am- 
ministrazioni Pubbliche, etc. 8vo. Milan, 1890. 

1893 

Agostini, C. : Ueber den Chemismus der Verdauung bei den Pel- 
lagrbsen Geisteskranken. Prag. med. Woch., 1893, XVIII, No. 32. 

: Manuale di psichiatria, Milano, 2 ed., 1900, p. 180. 

Pellizzi, G. P. : Sull' etiologia della pellagra in rapporto alle 
costanze tossiche prodotte dei microorganismi del maiz guasto. 
Ann. di freniat, Turin, 1893-94, IV, 309. 

, und Tirelli, V.: Aetiologie der Pellagra in 

Beziehung zu dem Gifte des verdorbenen Maises. Mitt, aus dem 



BIBLIOGRAPHY 



377 



XI, intern, med. Kongr. in Rom. Centralbl. f. Bakteriol. u Parasi- 
tenk. Jena, 1894, XVI, 186. 

1894 

Marie, P. : De l'origine des lesions exog. du cordon posterieur 
6tudi6es comparativement dans les tabes et dans la pellagre. Se- 
maine med., Par., 1894, XIV, 17. 

Tirelli, V. : Die Mikroorganismen des verdorbenen Maises. Mitt, 
aus dem Xi. intern, med. Kongress in Rom. Centralbl. f. Bakteriol. 
n. Parasitenk., Jena, 1894, XVI, 185. 

1896 

Gosio, B. : Ricerche batteriologiche e chimiche sulle alterazioni 
del mais, Letc] Riv. d'igiene e sanita pubblica. Roma, 1896, VII, 
825, 869. 

: Per l'etiologia della pellagra. Riv. pellagrol, ital., 

Udine, 1903, III, 177-184. Also : Atti del III Congresso pellagr. 



ital. 



Udine, 1907. 
e Ferrati, E. 



Sull' azione fisiologica dei veleni del 
maiz. Riv. d'igiene e. san. pubb., Roma, 1896, VII, 961-981. Also : 
Atti del 2° Congr. pellagr. di Udine, 1899. 

Vales, N. C. : Die Pellagra in Yucatan. 8vo. Berlin, 1896. 



1897 

Bombarda, A Pellagra em Portugal, a tetania, a catalepsia, e a 
confusao mental. Rev. Arch. f. Schiffs — u. Tropen-Hyg., Cassel, 
1897, I, 79. 

Jeanselme, : La Semaine MSdicale, 20, Oct., Par., 1897, XVII, 
380. 

1899 

Babes, V. : Patogenia pelagrei. Romania m^d., BucurescI, 1900, 
VIII, 265-272. Also transl. : Bull, de l'Acad. de m6d., Paris, 1900, 
3, s., XLIV, 170-178. Also : transl. Med. mod., Par., 1900, XI, 433. 
XI, 433. Also transl. : Allg. Wien. med. Ztg., 1900, XLV, 568 ; 580. 

: Ueber die Pellagra in Rumanien. Wien. med. Presse, 

1903, XLIV, 1185 ; 1239. 

: et Manicatide, Elena : Sur certaines substances 

spScifiques produites par l'organisme des pellagreux. Comp. rend. 
Acad, d sc. Par., 1900, CXXXI, 201-203. 

& Sion, V. : Lesiunile nerv6se in pelagra. Romania 

med., BucurescI, 1899, VII, 441-448. Also transl. : Verhandl. d. 
deutsch. path. Gesellsch, 1899. Berl., 1900, 310-319. Also transl. 
(Abstr.) : Verhandl. d. Gesellsch. deutsch. Naturf. u. Aerzte, 1899, 
Leipz., 1900, LXXI, pt. 2, 2 Hlfte, 24. 

: Die Pellagra. Spec. Path. u. Therap . . . 

Nothnagel., Wien, 1901, XXIV, 2. Hlfte., 3. Abth., 1-87, 2 PI. 



378 PELLAGRA 



Schreiber, : Ueber die Pellagra. Wien. med. Wochensch., 1899, 
XLIX, Nos. 9, 10, 11. 

1900 

Bonservizi : Nuovo metodo di cura della pellagra. Archiv. dl 
psich. e di scienze pen. Torino, 1900, XXI, 53-56. 

Rossi, E. : L'Indicanuria nella frenosi pellagrosa e negli stati 
psichici depressivi. Annali di freniatria, Torino, 1900, X, 1-19. 
(Changes in the nervous system.) p. 4. 

1901 

Articles in : Atti del Congresso Pellagrologico, I-IV, 1901-1910 
et seq. 

Articles in : Rivista Pellagrologica Italiana, organo bimestrale 
del Comitato Permanente della lega Internazionale contro la 
Pellagra e delle Commissioni Pellagrologiche del Regno. Udine, 
1901-10 et seq. 

Bietti, A. : Sulle alterazioni oculari nella pellagra. Riv. sper. di 
freniat., Reggio-Emilia, 1901, XXVII, 202-204. Also transl, in: 
Klin. Monatsbl. f. Augenh., Stuttg., 1901, XXXI, 337 ; 450. 

Ceni, C. : Ricerche sul potere riproduttivo e sulla ereditarietH 
nella pellagra. Riv. sper. di freniat., Reggio-Emilia, 1901, XXVII, 
94-109. 

: Articles in : Riv. sper. di freniat., Reggio-Emilia., 

1902-3-4. 

: Le propriety tossiche dell' Aspergillus fumigatus 

in rapporto colle stagione dell' anno. Beitrag zu pathol. Anat. 
u. z. allg. Path., Jena, 1903, XXXV, 528-535. 

. Ueber die Localisation der Aspergillussporen i. d. 

Mesenterialdriisen d. Pellagrakranken. Centralbl. f. allgem. Pathol, 
u. Anat., Jena, 1903, XIV, 465-468. 

: Potere patogeno dell' "Aspergillus ochraceus" e 

suo rapporto coll' etiologia e patogenesi della pellagra. XII Cong. 
Soc. freniatrica italiana, 1904. Also : Riv. sper. di freniat., 
Reggio-Emilia, 1905, XXXI, par c. 2, 231-244, 1 pi. 

: Di un aspergillo bruno gigante e delle sue pro- 
priety tossiche in rapporto colla pellagra. Riv. sper. di freniat., 
Reggio-Emilia, 1907, XXXIII, 1-15. 

: Sul ciclo biologico dei penicilli verdi. Riv. sper. di 

freniat., Reggio-Emilia, 1907-1908, XXXIII-XXXIV. 

: Sulla periodicita dei penicilli verdi in rapporto colla 

pellagra. Riv. sper. di freniat., Reggio-Emilia, 1908, XXXIV, 677- 
768. 

: Di una nuova specie di "Aspergillus varians" e 

delle sue propriety patogene in rapporto coll' etiologia della pel- 
lagra. XII Congr. della Soc. freniat. Ital. 

, and Besta, C. : ( Saggi diversi in : Riv. sper. di 

freniat., Reggio-Emilia, 1902-3, XXVIII-XXIX. 



BIBLIOGRAPHY 



379 



: Principii tossici degli "Aspergillus fumi- 

gatus e flavescens" e loro rapporti colla pellagra. Riv. sper. di 
freniat., Reggio-Emilia, 1902, XXVIII, 528-544. 

Sandwith, F. M. : La Pellagre. Bull. Institut Egypt, 1901. 

: Compt. rend. Cong. Egypt, de M6d., Cairo, 1904, 

I, 85. 

1902 

Antonini, G. : La pellagra ; storia, eziologia, patogenesi, profi- 
lassi. 24 mo. Milan, 1902. 

, : Sull' etiologia e patogenesi della pellagra. Pa- 

tologica, 1909. 

e Mariani : Sul potere antitossico del siero dei pella- 

grosi guariti. Gazz. med. Ital., Torino, 1902, LIU, 71-73. 

e : Contributo alio studio della sieroterapia 

nella pellagra. Bergamo, 1904. 

Finzi, Jacopo : Psicosi pellagrose. Boll, manico, di Ferrara. 
1902, Anni XXIX e XXX. 

, : II problema etiologico della pellagra. Patho- 

logiea, Genova, 1909, I, 456-464. 

Villalain, : Estado mental de los pelagrosos. AvilSs, 1902. 

1903 
Procopiu, G. : La pellagre. 8vo. Paris, 1903, p. 75. 



1905 

Deiaco, Pius : Beitrag zur Symptomatologie der Pellagra. Wien. 
Klin. Wochenschrift, 1905, XVIII, 908-911. 

: Ueber Localisation und Natur der pellagrosen Haut- 

symptome. Wien. klin. Wochenschr., 1907, XX, 967-975. 

Sturli, : Ueber die Aetiologie der Pellagra. Leipzig, 1905. 

Vedrani, : Sui sintomi psichici della pellagra. Soc. med. 
luecbese, 1905. 8vo. Lucca, 1905. 



1906 

Antonini, G. e'Tirelli. V. L'opera pellagrologica di Cesare Lom- 
broso. Turin, Bocca, 1906. 

Merk, Ludwig : Pellagra in friihester Kindheit ; nach Beobach- 
tungen des Herrn L. Cristoforetti ; gleichzeitig ein Beitrag zur 
Kenntniss von der Entwicklungsdauer der Pellagra. Wien. klin. 
Wochenschr., 1906, XIX, 467-471. 

: Die Hauterscheinungen der Pellagra. 7 Abbil- 

dunpen, 21 PI. Innsbruck, 1909. 

Otto, If. : Ueber die Giftwirkung einiger StSmme von "Asper- 
gillus fumigatus" und "Penicillum glaucum," nebst einigen Bemer- 
kungen iiber die Pellagra. Zeitsch, fur klin. Med., Berl., 1906, 
LIX, pp. 322-329. 

Paladino-Blandini : Tossici di ifomiceti. Archivio di farma- 
cologia. Siena, 1906, V, 606-644. 



380 PELLAGRA 



Terni, C. : Nouvelles connaissances sur l'6tiologie de la pellagre. 
Triller, : De la pellagre. These de Paris, 1906. 

Atti d. Cong, pellagrol. ital., 1906, Udine, 1907, III. 

1907 

Besta, C. : Sopra alcune controversie riguardo ai tossici pella- 
grogeni. Riv. sper. di freniat., Reggio-Emilia, 1907, XXXIII, 16-27. 

— : Sopra il potere patogeno dell' "Aspergillus fumi- 

gatus." XII Congr. della Soc. fren. Ital. 

Carriere, Louis : * Contribution a l'etude de la symptomatologie 
et de l'Stiologie de la pellagre a l'asile des aliened de Montpellier, 
8 vo. Montpellier, 1907. 

Corsini, A. : La mortalita per pellagra in Italia e particolar- 
mente in Toscana in questi ultimi anni. Propaganda sanitaria, 
Firenze, 1907, I, 70-74. 

von Deckenbach, C. : Sull' oospora verticilloides in rapporto alia 
pellagra. Arch, di Psichiat., Turin, 1907, XXVIII, 513-521. 

Galesesco, et Slatneano : Examen du sang et du liquide cephalo- 
rachidien dans la pellagre. Compt. Rend. Soc. de biol. ; Par., 1907, 
LXIII, 218. 

Gregor, A. : Beitrage zur Kenntniss der pellagrosen Geistes- 
storungen. Jahrb. f. Psychiat. u. Neurol., Leipz. u. W., 1907, 
XXVIII, 215-309. 

Le Fers, F. L. M. : La pellagre des Landes dans le passe 1 et dans 
le present. 8vo. Bordeaux, 1907. 

Marie, Auguste : Folies pellagreuses des Arabes. Nouvelle icon- 
ographie de la SalpStriere. Paris, 1907, XX, pp. 353-356, 1 pi. 

: La Pellagre. Paris, 1908. 

Regis, E. : Note sur l'6tat actuel de la pellagre dans les Landes, 
etc. J. mens, de neurol. et psych. No. 4. Avril, 1907. 

Tizzoni, G. : Nuove recerche batteriologiche sulla pellagra. Ren- 
dic. Accad. d. sc. d. 1st. di Bologna, 1907-8. n. s. XII, 19-21. 

: Contribution bacteriologique et experimentale sur 

la pellagre. (Publication du Ministere de 1' Agriculture, Rome, 
1909.) 

1908 

Balp, S. : Nuove vie di diffusione della pellagra. Propaganda 
sanitaria, Firenze, 1908, II, 40-42. Also : Gior. d. r. Accad. med.- 
chir. di Torino, 1908, LXXI, 50-56. 

Daniel, A.: Phlebite pellagreuse. Trib. meU Par., 1908, n. s. 
XL., 85. 

Guyot, G. : Studi anatomo-patologici ed istologici sulla pellagra 
sperimentali. Gazz. d. osp., Milan, 1908, XXIX, 1033-1036. 

Lotario, F. : Sul valore terapeutico del protargolo contro la pel- 
lagra. Rassegna di terap., Roma, 1908, XXVI, 797-803. 



BIBLIOGRAPHY 381 



Nicolas — et Jambon — . Pellagre. Annales de Dermatol., et 
Syphilog. 4° Series, IX, 1908. 

Padovani. E. : Alcune osservazione statistiche e cliniche sulla 
pellagra primaverile e la pellagra autunnale nella provincia di 
Pesaro-Urbino. Riv. pellagrol. Ital., Udine, 1908, VIII, 51-55. 

Savini-Lojani, L. : Studi ematologici sulla pellagra sperimentali. 
Gazz. d. osp., Milano, 1908, XXIX, 1130. 

1909 

Audenino, : Etiologia della pellagra. IVe Congres italien 
pellagr., Udine, Sept., 1909. 

Etiologie et Propbylaxie La Pellagre. Bulletin de l'office Inter- 
national d'Hygiene Publique, Par., 1909, I, 1266-1282. 

Sofer, L. : Die Pellagra in Oesterreicb und ibre Bekampfung a!s 
Volkskrankheit. Tberap. Monatscb., Berlin, 1909, XXIII, 216- 
219. 

1910 

Cappelletti, : II grado di alcalinita. del sangue nella frenosi 
pellagrosa. Boll, del manic, prov. di Ferrara, 1910. 

T. : Considerazioni Sulla mortality per pellagra, nel 

distretto capitanale di Trento. Boll. d. Ass. Med. Tridentina Trento., 
1910, XXIX, 151-162. 

Frisco, P. : Contributo alio Studio Sull' etiologia della pellagra ; 
considerazioni e commenti alia monographia del Dott. Odorisio col 
titolo "la pellagra nell' Italia meridionale." Ann. di Ippocrate, 
Milano, 1909-10, VI, 393-396. 

Raubitschek, H. : Zur Pathogenese der Pellagra. Wien. Klin. 
Wochensch, 1910, XXIII, 963-990. 



APPENDIX L 

Italian Law of July 21, 1902, for the Prevention 
and Cure of Pellagra.* 

Article 1. All persons are forbidden to sell, to 
keep for sale or to distribute in any form or to any 
one: 

(a) Indian corn that is immature, not well dessi- 
cated, mouldy or spoiled in any other way, whether 
in the form of grain or of meal. 

(b) All products obtained from such meal and 
those which, although prepared with normal and 
sound meal, become subsequently mouldy or other- 
wise spoiled. 

Art. 2. All persons are forbidden to introduce into 
the kingdom for use as food, corn or the products 
of corn that are spoiled or imperfect, even if the 
damage has occurred during transportation or in the 
warehouses. 

Art. 3. The circulation in the kingdom, or the 
grinding and utilization of spoiled or imperfect 
Indian corn and its products for other uses than 
human food are subject to the authorization of the 
prefect, or of the local authorities, under conditions 
fixed by special regulations. The lack of such 
authorization will lead to the immediate confiscation 
of the goods, in addition to the penalties established 
by law. 

•Appendices I and II are from an unpublished report to the 
Department of State on "Pellagra in Italy," by Vice Consul W. 
Bayard Cutting, Jr., from Milan, November 2, 1908. 

25— P. 



384 PELLAGRA 

Art. 4. Offences against the three foregoing 
articles must be reported to the judicial authorities 
by the officers and agents of the police and shall be 
punished by a fine of not less than L.51 and not 
more than L.2,000. 

The sanitary officer of the commune, as well as the 
mayor and the provincial doctor, shall report 
directly to the judicial authorities, offences against 
the present law and the corresponding regulations. 

Art. 5. The proceeds of the fines shall go to the 
benefit of local institutions for the prevention and 
cure of pellagra. 

Art. 6. The sanitary officers and inspectors shall 
have the right to visit the warehouses of dealers in 
grain and flour and the workshops of millers, bakers 
and pastrycooks, in order to ensure the observation 
of the present law. 

Art. 7. Every case of pellagra, even incipient, 
must be reported in the manner directed by articles 
45 and 47 of the law of public health of December 
22, 1888, No. 5849. 

Art. 8. The communes where endemic pellagra 
has been certified shall be subjected to the special 
rules of article 9 ff. of this law. 

The declaration of the application of these articles 
is to be made by decree of the prefect, under the 
advice of the provincial council of health. The 
decree goes into effect on the day of notification to 
the mayor, who is obliged to publish it on the self- 
same day. 

Art. 9. In the communes declared affected by 
pellagra, the dessication, the preservation and the 



APPENDIX I 385 

consumption for food of Indian corn and its products 
shall be subject to the inspection and direction of the 
government and local authorities. The provisional 
laws for the immediate execution of this and the 
following articles and the special regulations for 
enforcing them in a permanent manner shall be 
approved by the joint provincial administration, 
after hearing the provincial board of health and 
also the agrarian committees and other agricultural 
institutions legally existent in the province. 

Art. 10. In those communes that are declared to 
be infected with pellagra the prefect, after taking 
the advice of the provincial council of health and, 
where one exists, the provincial pellagrological 
commission, may order the construction or acquisi- 
tion of one or more dessicating machines for Indian 
corn, of capacity corresponding to the local needs. 
Their use is to be regulated by the rules prescribed 
by the regulations for the execution of this law. 
The prefect may likewise direct the commune to 
appoint a place where corn, being the private prop- 
erty of inhabitants not possessed of healthy store 
places, may be kept for them under hygienic condi- 
tions, in quantities adequate to the family needs for 
private consumption. 

Art. 11. The communal council shall make and 
keep a list of poor " pellagrosi" whose families can- 
not afford to supply them with a curative diet. 

The provision of curative food for the poor who 
are suffering from pellagra is obligatory. 

Art. 12. The indigent sick, for whom the insuffi- 
ciency or inefficiency of curative diet has been ascer- 



386 PELLAGRA 

tained must be taken to institutions, hospitals or 
other suitable places. 

Art. 13. The expenses accruing from articles 10, 
11 and 12 are to be defrayed by : 

(a) Private beneficence. 

(b) The help of public institutions. 

(c) The proceeds of fines (See Art. 5). 

(d) The aid of the commune and the province, in 
the proportion of one-half from each. 

(e) State subsidies. 

The assistance obtained under (a) and (b) 
shall go to diminish the consumer's share of the 
expense. 

Art. 14. In order to assist the local authorities 
in the application of the present law, provincial and 
local committees or "Pellagra" commissions may be 
constituted in the manner decided by the special 
regulations. To them may be delegated special work 
for the prevention and cure of pellagra, as well as 
for the introduction of better agricultural methods. 

Art. 15. In the case of refusal or hesitation on 
the part of any commune in the fulfillment of the 
obligations imposed by the present law, the prefect 
shall act with the power delegated to him by the 
provincial and communal law, with the aid, when- 
ever needful, of the united provincial administra- 
tion. 

Art. 16. In order to bring into effect preventive 
and curative measures, communes and provinces may 
unite according to local conditions and mutual con- 
venience. 



APPENDIX I 387 

Art. 17. The sum of L. 100,000 is to be put aside 
annually by the Minister of the Interior, for aid to 
the communes and for the establishment and support 
of curative institutions. The same provision is to 
be made by the Minister of Agriculture for the 
encouragement and aid of institutions of an 
economic nature and for the improvement of agra- 
rian methods. 

Art. 18. In communes declared to be infected by 
pellagra the Minister of Finance is authorized to 
have salt distributed gratuitously to the sick poor 
and to their families in quantity sufficient for their 
food, as directed by the sanitary officer. 

Art. 19. The execution of the present law shall 
be provided for by regulations approved by Royal 
decree and prepared by the Ministers of the Interior, 
of Agriculture and of Commerce, with the advice 
of the Superior Board of Health. 



APPENDIX II. 

Regulations for the Execution of the Law of 
July 21, 1902. 

Article 1. Whoever possesses or detains Indian 
corn or its products that are in the condition 
described under (a) and (b) of Art. 1 of the law 
must notify the local prefect or syndic immediately, 
stating (a) the quantity of the corn or its products; 
(b) the persons to whom it belongs and from whom 
it was obtained (c) the place in which it is kept; 
(d) the use to which it is to be put. 

Art. 2. (Until the permission mentioned in Art. 
3 of the law has been obtained, this grain cannot be 
disposed of in any way. The only exception to this 
rule is with regard to such portions of the corn as 
are destined for the food of families, known to be 
poor and unable to provide themselves with sound 
corn. ) 

Art. 3. Whoever sells, keeps for sale or distrib- 
utes in any way bread or food made of wheat flour 
mixed with Indian corn must inform the public by 
means of labels written in legible characters and 
placed in conspicuous places upon the goods. 

Art. 4. No Indian corn coming from foreign 
countries can be passed at the port or the frontier, 
nor allowed to circulate in the kingdom without 
having been first declared sound in conformity with 
the following provisions. An exception is made for 
shipments to foreign countries to which the usual 
rules for goods in transit shall be applied. 






APPENDIX II 389 

Art. 5. (A list of experts, qualified to test im- 
ported corn, to be kept in each province. From the 
list the prefect appoints an expert for any given 
test.) 

Art. 6. The expert, or experts, appointed by the 
prefect shall take, in the presence of the interested 
parties or of the captain of the ship, and with the 
help of the custom house officials, a number of sam- 
ples proportionate to the size of the cargo. (Methods 
of taking samples prescribed.) 

Art. 7. The above regulations apply also to goods 
arriving by land ; but the taking of samples may be 
done in one of the internal custom houses, provided 
the goods travel in closed and sealed cars. Samples 
must be taken from each car. 

Art. 8. (Prescribes the form of certificate to be 
made out when the samples are taken.) 

Art. 9. (The samples taken must be divided into 
three equal parts. Two of these are to be placed in 
sealed glass jars, bearing an identification card 
signed by the inspector and others present at the 
inspection. The third sample must be used for the 
summary inspection.) 

Art. 10. If on inspection the goods prove 
undoubtedly sound and fit for food, the inspector 
shall at once give a declaration (certificate) to this 
effect, and he shall consign to the harbour authori- 
ties or to the collector of customs samples sealed in 
the glass jars. These samples must be kept for at 
least three weeks in a dry place at the disposition 
of the sanitary authorities. 



390 PELLAGRA 

Art. 11. (If on examination it appears that the 
corn is manifestly spoiled, the inspector must imme- 
diately notify the prefect and, if necessary, the 
owners. One of the sealed jars must then be sent 
to the owners; the other to the nearest municipal 
laboratory or agrarian station, where it must be 
kept for three months in a dry place. During the 
few days following the owners may demand that 
the goods shall be tested at the institution or labor- 
atory to which the samples have been sent. If five 
days elapse without such demand, the merchandise 
shall be definitely adjudged unsound,) 

Art. 12. In case of uncertainty, Article 11 shall 
apply, but the inspection must be finished within ten 
days of the arrival of the samples. 

Art. 14. (Within ten days of receiving the 
notice the owners can appeal against the judgment 
declaring their goods unfit for food and demand a 
second inspection in state laboratories or some other 
laboratory indicated by the Minister of the Interior. 
The second inspection is final.) 

Art. 15. Until the inspection is completed the 
goods cannot circulate in the kingdom nor be ground 
nor used in any way for human food. Under Article 
14, nevertheless, suspected corn, or such as is 
declared unfit for food, can be unloaded in ware- 
houses provided that it is kept in separate store- 
rooms under the custody of custom house officials. 

Art. 16. (By admitting the unsoundness of a 
given cargo, the owners can avoid the expense of a 
test.) 



APPENDIX II 391 

Art. 17. It being ascertained that the merchan- 
dise is immature, not properly dessicated, mouldy, 
or in any other way spoiled or imperfect, the owner 
must notify in writing the prefect or sub-prefect 
of the use to which he intends to put It, and the 
place to which he intends to have it sent. The 
authorities having collected the necessary informa- 
tion may authorize the circulation of the merchan- 
dise in the kingdom, its being ground and used for 
purposes other than human food upon the following 
conditions : Indian corn must be directed to a dis- 
tillery of spirits or a factory of "fecole" and must 
travel in sealed trucks which cannot be opened 
except in the presence of customs or police agents. 
The "bolletta di spedizione" must be given to the 
authority that has given the permission. Meal must 
be denatured in the manner determined upon by 
ministerial regulations. Indian corn that is to be 
ground must be sent to mills designated by the 
authorities. The meal must be denatured according 
to the regulations. The use of Indian corn for the 
feeding of animals can only be permitted under 
guarantees that exclude its use as human food. 

Art. 21. (Fines imposed in districts free from 
pellagra shall be used for the benefit of the districts 
worst affected.) 

Art. 22. The report of each case of pellagra 
must state, in addition to the notices prescribed 
by the sanitary regulations, how long the person 
affected has lived in the commune and whether he 
has been ill before. 



392 PELLAGRA 

Art. 23. (When several cases of pellagra have 
appeared in persons previously unaffected who have 
lived at least a year in the commune the prefect shall 
apply Article 8 of the law.) 

Art. 24. (While observing the forms established 
by Article 9 of the law, communes may publish 
special regulations for the prevention and cure of 
pellagra. The minister of the interior, with the 
superior board of health, may refuse or annul any 
regulations contrary to the law or to the general 
regulations). 

Art. 25. The regulations directed by the above 
article must be applied immediately in communes 
declared affected with endemic pellagra without pre- 
judice to other measures that may be ordered by the 
prefect. 

Art. 26. In accordance with Article 14 of the 
law, the inspection of Indian meal, its care and pre- 
paration may be delegated to doctors or other per- 
sons of recognized capacity or skill. Corn taken to 
mills, bread shops or confectioners shall be inspected 
with special vigilance. 

Art. 27. In communes declared infected with pel- 
lagra where Indian corn known as quarantines or 
cinquantina is cultivated the authorities, assisted by 
the state, must encourage the cultivation of other 
cereals, potatoes, etc., in its place. 

Art. 28. (The use of communal dessicating plants 
must be gratuitous for all the inhabitants, and if the 
plant is available cannot be refused under pretext 
that the grain is the property of persons not belong- 
ing to the commune. But in this case compensation 



APPENDIX II 393 

must be made, not only for the cost of the firing, 
but also for the use of the plant.) 

Art. 30. The dessication in public plants of 
Indian corn that is obviously spoiled or mouldy is 
not allowed. When such corn belongs to persons 
notoriously poor it should be, if possible, exchanged 
for sound corn, in sufficient quantity for the needs 
of the family. Where there are no institutions for 
this purpose the exchange must be provided for by 
the commune. 

Art. 31. The list of poor "pellagrosi" shall be 
compiled and kept up to date by the municipal coun- 
cil (meeting). The list must indicate the name, age, 
sex and condition of the "pellagrosi" and the fam- 
ilies who live with them, and state briefly the pro- 
visions made for each "pellagroso." 

Art. 32. Curative food shall be administered in 
periods of each year, each period consisting of 
not less than 40 days. The maximum term for its 
administration shall be decided by the communal 
doctor. The diet must be approved by the "pellagro- 
logic" commission, or by the provincial doctor. 
Medicines are included in the curative diet. 

Art. 33. In order to be given curative food the 
patient must present a medical certificate, vised by 
the mayor. The food shall be given in sanitary sta- 
tions, economic kitchens or similar places, and can 
be given at the patients' homes only in cases of con- 
finement or advanced pregnancy, or when the doctor 
in charge certifies that the patient cannot be moved. 

Art. 34. The inefficacy or insufficiency of curative 



394 PELLAGRA 

diet, as also the inconvenience of administering it 
at home, must be certified by the doctor in charge, 
the medical officer or the sanitary officer. Upon the 
receipt of such a certificate the syndic shall issue an 
order of admittance to a "pellagrosario," hospital or 
other suitable place. 

Art. 39. Provincial or communal pellagra com- 
missions shall be constituted upon the decree of the 
minister of the interior, together with the ministers 
of agriculture, industry and commerce, upon the 
demand of the provincial or local councils. The 
provincial doctor, the professor of hygiene at the 
university, if there is one, the sanitary inspector and 
a teacher of an elementary school shall be ex-officio 
members of the commission. 

Art. 40. The duties of the commission shall be: 

(a) To care for the matters appointed by the law. 

(b) To administer the funds for curative and 
prophylactic measures against the disease. 

(c) To inspect and govern the various institu- 
tions. 

(d) To call to the attention of the authorities all 
cases requiring official intervention. 

(e) To encourage improved methods in agricul- 
ture. 

(f ) To spread among the school children instruc- 
tion in regard to pellagra, its causes and remedies. 

(g) To compile pellagra statistics. 

(h) And to perform such other duties as shall be 
assigned to them by competent authorities. 

Art. 47. (Methods of distributing free salt.) No 
family shall be given more than 5 kilograms in one 



appendix n 395 

week. [ ?] The quantity to be given to each indi- 
vidual shall not exceed 8 kg. per annum for adults 
of 15 years or over, or 5 kg. for children. 

Abts. 48, 49. (Punishments for evasion or in- 
fringement of provisions of Article 47.) 



APPENDIX EL* 

Proclamation of the Most Illustrious and Most 

Excellent Purveyors and Superior 

Purveyors to Health. 

(Venice 1776.) 

The pernicious effects which may result to the 
health of the poorer inhabitants, and, especially 
those of the villages of Polesine, Padovano and 
Veronese, from the wretched food made from imma- 
ture and spoiled corn (Sorghi Turchi), which has 
been recovered in great quantities from lands sub- 
merged by floods, and damaged by the overflow of 
rivers in those places, pledge the vigilance and zeal 
of this Magistrate to prevent, by vigorous measures, 
the homicidal diseases and epidemics which are 
accustomed to result from such eventful facts. In 
consideration also of the report of the most able 
doctors of medicine of Kovigo, transmitted with 
recent letters by that Illustrious Kepresentation, the 
Most Illustrious and Most Excellent Superior Pur- 
ve3^ors and Purveyors to Health deem it necessary to 
make publicly known and understood: 

I. That it is intended resolutely to inhibit every 
one from gathering, or having gathered, from inun- 
dated valleys, spoiled corn; and to require those 
who may have already gathered such corn to report 
to the Health Office the quantity gathered and the 
place where it may be stored, in order that all those 
measures and precautions may be put into effect 

♦From Trattatto Profilattico e Clinico della Pellagra, Lombroso. 



APPENDIX III 397 

which are deemed necessary in the salvation of a 
good cause, and which are practiced at other similar 
times. 

II. That no one must, either for human food or 
even for food of animals, make use of corn recov- 
ered from water when it has thereby become spoiled 
and of bad odor : it is also equally forbidden to mix 
such corn with other sound grain for facilitating its 
sale, and so having it consumed either by the inhab- 
itants of the villages themselves or their dependen- 
cies. 

III. In order that every one may be effectively 
prohibited from bringing to the public markets even 
a small quantity of said grain, spoiled and of bad 
odor, with the object of sale or exchange, the Grain 
Brokers must give notice to the Health Office 
regarding all corn of this kind which may be found 
to exist privately or in the public markets, and for 
this purpose ulterior expedients may be adopted. 

IV. It is enjoined, however, as a precise duty of 
each one of the Health Offices of the said provinces 
to send one of their Purveyors, along with the Chief 
Physician and Soldiers, for the inspection of the 
quality of the grain or meal wherever there may be 
evidence that the prohibited quality is used; and 
such grain, if found, shall be put in a place aside, 
well secured, as well as all similar lots which show 
such evidence; and notice thereof shall be promptly 
transmitted to the Magistrate by the respective 
Illustrious Representatives, where, in conformity 
with the facts of the examination, he may deliberate 
upon the destination of said grain or meal as to how 



398 PELLAGRA 

best shall be determined what the serious consid- 
erations of the case may demand. 

V. Corn of the proscribed quality, when carried 
to the mills, shall not be ground, and it shall be the 
duty of all Millers to hold such corn received by 
them, and to carry all the evidence to that Health 
Office, which is empowered to act in respect to such 
evidence. 

VI. All Medical Doctors of the City, County and 
Subject Villages, must transmit weekly to their 
respective Health Offices, notice of all the sick in 
whom there shall be doubt as to whether such sick- 
ness be due to their feeding on said spoiled grain, 
indicating the character and symptoms of their 
illness, for the prompt institution of the necessary 
measures. 

VII. Shopkeepers or Grain Vendors must give 
notice to the Health Office of any quantity, what- 
ever, of spoiled corn which may be found to have 
been received by them, and the sale of such grain by 
them is prohibited under the penalty in force at that 
time and place, in whatever way the grain may be 
sold or mixed with other grain of good quality. 

VIII. One of the principal duties of the Illus- 
trious Representatives, and of the Health Office, 
shall, however, be that of preventing the importa- 
tion or exportation of said spoiled grain, in order 
that their own territory, or others bordering thereon, 
may not become involved in the danger of trouble- 
some consequences, and for this purpose they shall 
give to the Authorities, and the Deputies of the Vil- 



APPENDIX 111 399 

lages, orders which they deem most suitable and 
fitting. 

IX. The process of inquisition shall be held pub- 
licly, and the judgments delivered secretly, so that 
aid may be thus secured in the discovery of the 
transgressors, who shall be severely punished accord- 
ing to the sanitary laws, the Magistrate trusting 
that from the vigilance and zealous solicitude of 
the respective Illustrious Representatives and 
Health Officers he shall receive support in the most 
efficacious manner for the performance of the essen- 
tial, prudential measures, whereby may be secured 
the object contemplated, namely, guaranteeing 
against menacing disasters, the precious health of so 
many subjects, too many having already been 
destroyed by the losses suffered. 

These presents ordered printed, published and 
transmitted in copy to the Most Excellent Podesta 
and Vice-Captain of Padova, and to the Illustrious 
Captain and Vice-Podesta of Verona, and the 
Podesta and Captain of Rovigo, whence to be 
diffused in the cities and territories respectively, as 
well as to all the Governments subordinate to their 
jurisdiction, and to the laws of the Health Offices; 
and published by every Parish Priest of the villages 
on festal days during the hour of the greatest con- 
course of people, and republished every first Sunday 
of each month till they come to universal knowledge 
for their punctual performance. Et sic, etc. 

Given by the Most Excellent Magistrate to the 
Health of Venezia, the 22nd of November, 1776. 



26— P. 



400 



PELLAGRA 



Almoro Pisani, Superior Purveyor. 
Polo Querini, Superior Purveyor. 
Marc' Antonio Zustinian, Purveyor. 
Gerolamo Antonio Valleresso, Purveyor. 
Gio. Antonio Ruzini, Purveyor. 

Giuseppe Antonio Gariboldi, Secretary. 
The 27th day of November, 1776, 

Published in the customary places. 
Printed by the Sons of Antonio Pinelli, Ducal Printers. 



From the Bibliography of Pellagra of the famous Librarian, 
F. Salveraglio, 1887, Milano. 



APPENDIX IV. 

The following translation is an example of the 
kind of popular pamphlets which are distributed in 
Italy for the education of the people in the prophy- 
laxis of pellagra. This one was prepared by Dr. 
Antonini and issued by the Pellagrologic Commis- 
sion of the Province of Udine in 1905 : 

ADVICE AND RULES FOR AVOIDING PEL- 
LAGRA. 

Spoiled corn is the cause or Pellagra, and corn 

readily becomes spoiled, mouldy or poisonous when 

harvested too early, before it is ripe, and stored in 

places which are damp or poorly ventilated; it may 

also be of poor quality when imported from some 

other place and may contain a large percentage of 

damaged grains. 

* * * 

Cinquantina is a variety of corn which should be 
used only for feeding animals. 



Spoiled corn may be recognized by its pale or 
greenish color, by the shriveled and cracked surface 
of the grains which are also covered with greenish, 
bluish or brownish spots, by its musty odor and its 
bitterish, disgusting taste. 

The damaged corn also weighs less than sound 
corn; and the surface of spoiled grain lacks the 
shining appearance of the sound article. 



402 PELLAGRA 

Keep your corn then in places well dried and 

AIRED. 

Distrust white corn because it is more likely to 
spoil than other kinds. 

Imported corn is frequently damaged. 

* * * 

Keep watch over your corn while it is being 
ground in the mills of the country. 

If you have carried good corn to the mill see to it 
that you receive meal ground from that corn, and 
do not allow the miller to substitute meal ground 

from inferior grain. 

* * * 

If your corn is ground by a roller mill (a cilin- 
dro) the spoiled grains are not likely to be ground 

into the meal. 

* * * 

The establishment of a communal, co-operative 
or independent bakery is a great benefit in a sec- 
tion where pellagra is very severe. 

The utmost care should be used when one under- 
takes the PREPARATION AND BAKING OF BREAD AT HOME. 

* * * 

Instead of spending your money in wines and 
liquors, buy wheat bread ; limit your use of polenta. 
If you have milk, eggs, cheese, limit the sale of these 
articles to others, and use at least a part of such 
products for your own home food. 

* * * 

Reduce the cultivation of corn; extend cultiva- 
tion on your low lands and do not grow corn in 
mountainous regions or in very moist soils. 



APPENDIX IV. 403 

Do not be ashamed to go to the doctor if you are a 
pellagrin; and have yourself entered at the 

LOCANDA SANITARIA OT at the ECONOMIC KITCHEN. 

Get cured in time and so avoid the hospital or 
the insane asylum. 

Eemember that the Law against Pellagra re- 
quires a curative diet for pellagrins. It is your 
right to demand it, and your duty to procure it. 

* * * 

The cleanliness and heai/thfulness of your 
homes are necessary conditions for preventing the 
moulding of corn which is kept in your houses. 

Never keep your corn in bed rooms, and see to it 
that you have proper places for the storing and 

SEASONING OF YOUR GRAIN. 

Keep the corn dry. 

* * * 

Profit by your instruction in agriculture, and 

better your crops. 

* * * 

Exert yourselves to co-operate with others for 
your own salvation by acquiring knowledge of, 
and interest in the application of the Law against 
Pellagra. 



APPENDIX V. 

Corn Crop of Countries Named, 1907. 

North America: Bushels. Bushels. Bushels. 

United States 2,592,320,000 

Canada : 

Ontario 22,949,000 

Quebec 1,420,000 24,369,000 

Mexico 70,000,000 2,686,689,000 



South America: 

Argentina 71,768,000 

Chile 1,500,000 

Uruguay 5,359,000 78,627,000 



Europe : 

Austria-Hungary : 

Austria 16,599,000 

Hungary proper. . ..155,616,000 

Croatia-Slavonia .. 17,934,000 

Bosnia-Herzegovina . 6,468,000 196,617,000 

Bulgaria 12,000,000 

France 24,027,000 

Italy 88,428,000 

Portugal 9,000,000 

Roumania 57,576,000 

Russia : 

Russia proper. . . . 41,903,000 

Poland 1,000 

Northern Caucasia.. 8,860,000 50,764,000 

Servia 17,691,000 

Spain 25,372,000 481,475,000 



Africa : 

Algeria . .. 402,000 

Cape of Good Hope.. 3,550,000 

Egypt 35,000,000 

Natal 3,300,000 

Sudan (Anglo-Egyptian) 300,000 42,552,000 







APPENDIX 


V 


405 


Australasia : 










Australia : 










Queensland. 




3,820,000 






New South 


Wales 


5,945,000 






Victoria. . 




727,000 






Western Australia. 


1,000 


10,493,000 




New Zealand . 






419,000 


10,912,000 




total 




Grand 




3,300,255,000 



From the Year Book, U. S. Department of Agriculture, 1908, 
page 597. 

"This statement from the Yearbook of the De- 
partment of Agriculture includes practically all 
corn-producing countries for which either official or 
trustworthy commercial estimates of production are 
available. It is well known, however, that the crop 
is now cultivated in practically all countries where 
the climate is favorable to its growth and matura- 
tion. It is raised in all the States of Central and 
South America, in all countries of Southern Europe 
including, besides those named in the Yearbook, 
Greece and Turkey, in Asia, and probably in all 
Asiatic countries where climate is adapted to the 
culture. 

"The official reports of the Government of British 
India return about 6,000,000 acres under maize in 
that dependency annually, but include no data as to 
the quantity produced. A statement furnished this 
Department by the Japanese Director of Statistics 
gives the area under corn in Japan, in 1906. as 123,- 
076 acres, yield, 3,127,748 bushels. These data, com- 
bined with those in the Year Book, comprise prac- 
tically all statistical information available on the 
world corn crop." — Statement kindly furnished by 



406 PELLAGRA. 

Mr. Victor H. Olmstead, Chief Bureau Statistics, 
Agricultural Department. 



PRODUCTION OF CORN IN THE UNITED STATES, 1908, BY 
STATES. 

State or Territory. Bushels. 

Maine 567,000 

New Hampshire 1,092,000 

Vermont 2,499,000 

Massachusetts 1,818,000 

Rhode Island 428,000 

Connecticut 2,395,000 

New York 24,250,000 

New Jersey 10,564,000 

Pennsylvania 57,275,000 

Delaware 6,240,000 

Maryland 24,705,000 

Virginia 50,050,000 

West Virginia 23,962,000 

North Carolina.. 50,166,000 

South Carolina 29,229,000 

Georgia 53,750,000 

Florida 6,584,000 

Ohio 136,675,000 

Indiana 137,835.000 

Illinois 298,620,000 

Michigan 60,420,000 

Wisconsin 49,674,000 

Minnesota 46,835,000 

Iowa 287,456,000 

Missouri . .203,634,000 

North Dakota ■. . . . 3.856.000 

South Dakota .. 57,677,000 

Nebraska 205,767,000 

Kansas 156,200,000 

Kentucky 84,823,000 

Tennessee 83,080,000 

Alabama 44,835,000 

Mississippi 45,845,000 

Louisiana 33,898,000 

Texas 201,848,000 

Oklahoma 122,239,000 

Arkansas 54,035,000 

Montana 94,000 

Wyoming 84,000 

Colorado 2,586,000 



APPENDIX V. 407 

New Mexico 1,755,000 

Arizona 432,000 

Utah 323,000 

Idaho 174,000 

Washington 332,000 

Oregon 445,000 

California 1,600,000 

Total 2,668,651,000 

Average price per bushel, United States, 60.6 cents. 

From the Tear Book, U. S. Department of Agriculture, 1908, 
pages 599 and 603. 



REFERENCES 



Adriani, 45, 46. 

Agostini, 376. 

Ahmed ibu Hassan el Rah- 

shidy el hakeem, 372. 
Albera, 370. 
Alberti, 20. 
Albertotti, 230. 
Allbutt, 2S3, 353, 354. 
Allen, 250. 357, 358. 
Alessandrini, 141. 
Allioni, 20, 227, 370. 
Allison, B., 364. 
Allison, W., 364. 
Alpago-Novello, 193, 211, 

214, 227. 
Alsberg, 41, 43, 357, 362, 

364. 
Anderson, P. V., 364. 
Anderson, W., 364. 
Antoniu, 22, 23, 375. 
Antonini, 125, 177, 379, 401. 
Arnould, 342. 
Ashford, 74. 
Anbert, 177. 
Audenino. 11, 381. 
Aulde, 357. 

B— , W. A., 357. 

Babeock, 73, 355, 356, 360, 

364. 
Babes, 19, 78, 116, 125, 134, 

144, 149, 152, 182, 255, 

261, 275, 310, 311, 377. 
Bacon, 364. 
Bailey, E. B., 357. 
Bailey, T. W. L., 358. 
Baillarger, 178, 259, 260, 

372, 376. 
Balardini, 84, 122, 327, 330, 

372. 374. 
Balestra, 49. 
Balp, 380. 
Baruffi, 268. 

Bass, 145, 357, 358, 363, 365. 
Bassoe, 177. 



Bauchert, 330. 

Beauchamp, 239. 

Beck, 366. 

Beketoff, 315. 

Bell, 320. 

Bellamy, 71, 355, 363. 

Bellini, 374. 

Belmondo, 116, 192, 214, 

219, 221, 223, 224, 229, 

263, 265, 266, 269, 276, 

376. 
Bemis, 71. 
Bennati, 375. 
Berger, 376. 
Bergerons, 345. 
Bernard, 191. 
Besta, 377, 3S0. 
Bianchi, 178, 179, 354. 
Bietti, 277, 378. 
Biffi, 32, 191, 374. 
Billod, 219, 263, 352, 372, 

373. 
Black, 364. 
Bloss, 368. 
Blue, 365. 
Bodio, 316, 317. 
Boerio, 371. 
Bombarda, 377. 
Bona, 370. 
Bondurant, 72, 357. 
Bone, 365. 
Bonfigli, 211, 375. 
Bonnet, 376. 
Bonservizi, 378. 
Bordoni-Uffreduzzi, 89, 96. 
Bouchard, 164, 263, 270, 

347, 372, 375. 
Bourgade, 347. 
Bo wen, 177, 365. 
Braddon, 65. 
Brault, 155. 
Briere de Boismont, 158, 

371. 
Brown, A. C, 355. 
Brown, R. D., 357. 



410 



PALLAGRA 



Brown- Sequard, 189. 
Brugnatelli, 83. 
Brnnetti, 263. 
Bryan, — , 357. 
Buchanan, 358. 
Bncknill, 179, 352. 

Calderini, 164, 192, 193, 202, 

215, 226, 245, 318, 372. 
Cales, 345. 
Cainis, 318. 
Camurri, 278, 279. 
Cantlie, 365. 
Cappelletti, 3S1. 
Card, 355. 
Carriere, 380. 
Carter, 357. 
Casal, 19, 27, 121, 169, 170, 

171, 369. 
Casenave, 148, 352. 
Castellani, 365. 
Ceni, 93, 126, 127, 128, 129, 

135, 378. 
Ceresoli, 305. 
Cerri, 20, 370. 
Ceru, 53. 
Cesati, 84. 
Chalmers, 365. 
Chambrelant, 30. 
Chevalier-La vaure, 30. 
Chiarugi, 268, 371. 
Cipriani, 184. 
Clarke, 357, 359. 
Clymer, 351. 
Coindet, 28. 
Cole, 312, 357, 358, 365, 367, 

368. 
Coletti, 302. 
Comin, 345. 
Contreras, 28. 
Cooper, 365. 
Copland, 352. 
Corlett, 354, 365. 
Corsini, 380. 
Cortez, 330. 
Costa. 21. 

Costa Hat, 40, 327, 346. 
Courbin. 344. 
Courtellemont, 239. 
Creighton, 353. 



Cross, 356, 363. 
Cuboni,, 87, 88, 98. 
Cutting, 5, 290, 293, 294, 
295, 297, 298, 356, 381. 

Dabos, 345. 

Dalla Rosa. 218. 248. 

Daniel, 380. 

Dankoff, 319. 

Daspit, 363. 

Dearborn, 365. 

de Boismont, 158. 

de Calviere, 345. 

Dcchambre, 19. 

De Giaxa, 125, 375. 

Deiaco, 171, 379. 

De Jarnette, 359, 363. 

Dejean, 344. 

Dejerine, 375. 

Delcourt, 365. 

del Pinto, 28. 

de Pietra Santa, 330. 

Desmaisons, 30. 

De Wolff, 70, 352. 

Dide, 267. 

Di Donna, 125. 

Dietrich, 320, 321. 

Dock, 359. 

Dorsey, 363. 

Dotti, 373. 

Dozons, 345. 

Drewry, 359, 363, 365. 

Duplais, 346. 

Duplan, 346. 

Dupr§, 107. 

Dupuy, 30. 

Duse, 267. 

Dyer, 72, 358, 359. 

Eason, 365. 

East, 25. 

Edwards, 359. 

Egan, 359. 

Eiker, 363, 365. 

Ellia, 327. 

Elmer, 359. 

Erba, 82, 94, 115, 116. 

Eskridge, 359. 

Fanzago, 167, 262, 368, 370 
Farquhar, 352. 



REFERENCES 



411 



Fasoli. 329. 

Feijoo, 360. 

Felix, 22, 24S, 330. 

Ferrario, 240. 

Ferrati, 110, 376. 

Ferrero, 350. 

Festler, 269. 

Fileti, 97. 

Fillipi, 201. 

Finzi, 177, 379. 

Fitzgerald, 365. 

Flarer, 196. 

Fox, H., 154, 35S, 365. 

Fox, T., 352. 

Frapolli, 19, 20, 147, 170, 

369. 
Frione, 20. 
Frisco, 381. 
Frontis, 356. 
Frua, 32S. 
Fua, 375. 

Galesesco, 267, 380. 

Garovaglio, 85. 

Gaumer, 69, 358, 365. 

Gautier, 329. 

Gazaban, 345. 

Gazaillan, 345. 

Gemma, 372, 373. 

Gherardini, 20, 369. 

Giaeosa, 94. 

Gianelli, 269. 

Gibelli, 86, 100. 

Gibert, 259. 

Girma, 30, 239. 

Goldtbwaite, 359. 

Gorizia, 96. 

Gosio, 91, 116, 124, 377. 

Gottheil, 365. 

Graffky, 328. 

Grawitz, 328. 

Gray, 70, 352. 

Green, 358, 365. 

Gregor, 151, 159, 161, 175, 

177, 178, 179, 180, 380. 
Griffin, 356, 359. 
Griffini, 270. 
Grimaldi, 201. 
Grohe, 93. 
Guff art, 319. 



Giihring, 320. 
Guiteras, 74, 359. 
Guyot, 3S0. 

Hameau, 29, 371, 372. 

Harmon, 347. 

Harris, 72, 275, 354, 355, 

356, 35S. 
Hansemann, 116. 
Hayne, 74. 
Hedges, 135. 
Heider, S8, S9, 96, 376. 
Henderson, 359. 
Hewitt, 359. 
Hieronimis, 264. 
Hirscb, 375. 
Hodges, 361. 
Holland, 20, 44, 300, 351. 
Hopkins, 25. 
Howard, 140. 
Howden, 352. 
Hummel, 3(53. 
Hunter, 140. 
Husemann, 330. 
Hyde, 165, 169, 177, 359, 365. 

Iturbide, 28. 

Jaeini, 32, 40, 318, 334. 
Jaillard, 328. 
Jambon, 155, 381. 
Jansen, 20, 370. 
Jarrell, 363. 
Jeanselme, 377. 
Jelks, 365. 
Jonnson, 351. 

Kaposi, 167, 353. 
Kerr, J. W., 358, 363. 
Kerr, W., 351. 
Kerr, W. J. W., 71. 
King, H. D., 359, 366. 
King, J. M., 356, 358, 359, 

365. 
Kingsford, 316. 
Kirk, 359. 
Koenig, 320, 321. 

Labus, 263, 268, 269. 
Lalesque, 371. 
Lancaster, E. H., 360. 



412 



PELLAGRA 



Lancaster, R. A., 356. 
Landouzy, 131, 193, 346, 

347, 352, 372. 
Lasegue, 235. 
Laurens, 373. 

Lavinder, 73, 136, 356, 358, 
3G0, 362, 363, 366, 368. 

Leach, 356. 

Leborgne, 267. 

Lee, 356, 363. 

Le Fers, 380. 

Lemaire, 345. 

Lend way, 23. 

Leplat, 328. 

Lestelle, 345. 

Letheby, 321. 

Le Vacher de la Feutrie, 
370. 

Liberal!, 207, 262, 263, 371. 

Lockwood, 366. 

Lolli, 53. 

Lombroso, 3, 4, 5, 7, 8, 12, 
17, 32, 53, 84, 94, 96, 98, 
107, 116, 120, 122, 124, 
135, 147, 159, 176, 193, 
200, 201, 214, 215, 252, 
255, 261, 263, 265, 271, 
280, 2P0, 301, 314, 316, 
322, 328, 329, 330, 332, 
333, 335, 336, 342, 344, 

348, 349, 373, 394. 
Long, 74, 164, 366. 
Lotario, 380. 

Low, 357. 
Lunney, 359. 
Lussana, 218, 328, 374. 

Mackenzie, 362. 
MacNeal, 366. 
Maddox, 359. 
Mai ret, 347. 
Majocchi, 87. 
Manassei, 330. 
Manfredi, 196. 
Manicatide, 125, 376. 
Manly, 5. 

Manning, 67, 69, 358. 
Manson, 66, 131, 132, 355. 
Mantegazza, 342. 
Manzini, 47, 373. 



Maragliano, 375. 

Marce, 263. 

Marchand, 344. 

Marchi, 264. 

Mariani, 116, 125, 378. 

Marie, A., 3, 4, 8, 11, 26, 

122, 126, 130, 239, 358, 

366, 380. 
Marie, P., 266, 267, 377. 
Marinesco, 255, 261, 275. 
Marzari, 32, 121, 369, 370. 
Mattirolo, 86, 100. 
McCafferty, 72, 360. 
McCall, 364. 

McCampbell, 41, 355, 356. 
McConnell, 356, 358. 
Merk, 161, 163, 164, 168, 

169, 170, 171, 172, 2S0, 

286, 379. 
Merrill, 355. 
Merriwether, 366. 
Mesnil, 139. 
Miles, 366. 
Miller, 359. 
Minor, 360. 

Miraglia, 34, 48, 49, 51. 
Mitchell, 359. 
Mobley, 358. 
Mongeri, 179. 
Monti, 90, 93. 
Moore, 355, 356, 360, 362. 
Moorer, 360. 
Morelli, 262. 
Morichon; 239. 
Moscati, 20. 

Nardi, 190, 193, 218, 227, 

262, 263. 
Nesbit, 202. 
Neuffer, 356. 
Neusser, 54, 177, 375. 
Newman, 363. 
Nicholas, 155. 
Nichols, 250, 358, 366. 
Nicolaidi, 22. 
Nicholas, 381. 
Nisbet, 358, 360. 
Nobili, 193. 
Norris, 366. 

Odoardi, 20, 193, 369. 



REFERENCES 



413 



Orsolato, 270. 
Osier, 360. 
Otto, 379. 

Ottolenghi, 8, 89, 94, 96, 
196, 197, 232. 

P— . 351. 
Padovani, 3S1. 
Paladino-Blandini, 379. 
Paltauf, SS, 89, 95, 376. 
Pa n i cbi, 329. 
Paolini, 247. 
Papinian, 261, 276. 
Parhon, 261, 276. 
Parker, 35S, 363. 
Parmentier, 339. 
Pasquali, 34. 
Pavesi, 317. 
Peacock, 352. 
Pedebidou, 346. 
Pesrram, 366. 
Pellizzi, 116, 117, 119, 123, 

376. 
Pellogio, 116. 
Perrusset. 338. 
Perry, 366. 
Perugini, 302. 
Pesckel, 9S. 
Pbenix, 363. 
Piccinini, 49. 
Piedmont Commission, 37, 

247, 254. 
Pittman, 366. 
Pixley, 361. 
Pollock. 361. 
Pons Sanz, 353. 
Pope, 71. 
Powers, 356. 
Poznanski, 189. 
Procopiu, 150, 151, 152, 156, 

159, 160, 161, 162, 163, 

164, 166, 167, 168, 171, 

178, 379. 
Pruner, 372. 

Radcliffe-Crocker, 354. 
Raggi, 227. 
Rampoldi, 197. 
Rudolph, C. M.. 357, 361. 
Randolph, J. H., 357, 358, 
367. 



Raubitschek, 141, 381. 

Ray, 354. 

Rayer, 351. 

Raymond, 164, 376. 

Reed, 366. 

Regis, 29, 31, 176, 179, 218, 
238, 254, 261, 347, 380. 

Resnaud, 189. 

Righetti, 239, 261. 

Rizzi, 190, 262. 

Roberts, 355. 

Robertson, 366. 

Robolotti, 207. 

Rochard, 316. 

Roel, 27. 

Robrer, 35S, 363, 366. 

Rolleston, 354. 

Roncoroni, 201, 215, 216, 
227, 228, 229, 230, 232. 

Ronlin, S3. 

Rossi, 261, 378. 

Roussel, 28, 131, 148, 152, 
161, 162, 163, 167, 185, 
280, 2S6, 299, 327, 332, 
338, 342, 343, 344, 345, 
347, 348, 349, 371. 

Roussilbe, 337, 345. 

Rudolpb, 357, 361, 366. 

Russel, 366. 

S. , 361. 

Sabrazes, 207. 
Sacchi, 254. 
Sage, 366. 

Salveraglio, 376, 398. 
Sambon, 5, 132, 134, 136, 

137. 139, 140, 354, 366. 
Sandoval, 28. 
Sandwith, 5. 25, 63, 66, 71, 

151, 153, 154, 155, 182, 

256, 353, 354, 356, 358, 

378. 
Saunders. C. H., 361, 364. 
Saunders. E. B., 155, 168, 

172. 203, 358, 361. 
Savini-Lojani. 3S1. 
Schedel. 148, 352. 
Scheube, 151, 153, 154, 155, 

156, 157, 160, 354. 
Schilling, 330. 



414 



PELLAGRA 



Sehmdler, 25. 

Schreiber, 337. 378. 

Schultz, 32S. 

Schultze, 3G4. 

Scott, 367. 

Searcy, 72, 355, 357. 

Selini, 329, 330. 

Sepilli, 203, 375. 

Sheel, 361. 

Sherwell, 71, 72, 353, 354. 

Shoemaker, 361. 

Siler, 250, 358, 361, 367. 

Silver, 367. 

Sion, 10, 78, 116, 144, 149, 
152, 182, 261, 275, 376. 

Slack. 364. 

Slatineano, 268, 380. 

Sloan, 71. 

Smith, 25. 135, 361. 

Socor, 164. 

Sofer, 381. 

Soler, 150, 185, 370. 

Spessa, 371. 

Stelwagon, 354. 

Stephanowics, 171. 

Stem, 168, 367. 

Stoddart, 180, 356. 

Strachan, 63, 64, 65, 66. 

Strambio, 20, 44, 147, 148, 
162, 163, 164, 172, 174, 
185, 190, 192, 194, 200, 
224, 239, 262, 270, 290. 
300, 351, 370, 374. 

Strambio, Gaetano. Jr., 376. 

Sturli, 378. 

Takach, 62. 
Tamburini, 263, 374. 
Tanzi, 161, 176, 177, 179, 

362. 
Tappan, 367. 
Taylor, I. M., 355. 
Taylor, J. H., 355, 358, 362. 
Tellez, 28. 
Terni, 380. 
Terzaghi, 20. 
Thayer, 362. 
Thiery, 369, 370. 
Thomas, 364. 
Thompson, 355. 



Thrash, 364. 
Thypaldos, 23, 24. 
Tiraboschi, 91, 92. 
Tirelli, 90. 116, 123, 375, 

377, 379. 
Tizzoni, 93, 94, 126, 129, 

130, 136, 210, 329, 375, 

380. 
Tonnini, 179, 224, 227, 229, 

231, 232, 263, 264, 375. 
Torrence. 359. 
Towle, 177, 365. 
Townsend, 351, 362, 364. 
Trask, 367. 
Triller, 25, 27, 3S0. 
Tucker, 367. 
Tuczek, 227, 264, 266, 272, 

353, 354, 376. 
Tuke, 179, 272, 352. 
Turck, 367. 
Turner, 362. 
Tyler, 70. 

Uffelmann, 321. 

Vales, 170, 376. 

Vanderhoof, 364. 

Van Dyne, (>6. 

Van Harlingen, 353. 

Van Wart, 364. 

Vassale, 221, 269. 

Vedrani, 177, 378. 

Verdoux, 346. 

Verga, iro. 215, 219, 237, 

252, 262, 263, 268, 269, 

371, 375. 
Villalain, 379. 
Villergois, 270. 
Virchow, 316. 
von Deckenbach, 11, 135, 

379. 

War field. 362. 

Walker, 362. 

Warnock, 5, 26, 177, 239, 

310, 353, 354, 358. 
Warren, 367. 
Warthin, 367. 
Watson, E. J., 358. 



REFERENCES 



415 



Watson, J. J., 5, 73. 1G9, 
173, 355, 358, 3G2, 307. 

Wangh, 307. 

Webster, 3GS. 

Wei ton, 302. 

Whaler. E. M., 197, 350, 
350. 302. 

Whaley. J. S., 358. 

White, 5, 35S. 

Wilks, 352. 

Williams, C. F., 300. 

Williams, D. J.. GS, 35S. 

Williamson. 302. 

Wilson, 353. 

Winternitz, 375. 

Winthrop, 358, 305, 307, 
308. 



Wood, 250. 
Wood, E. J., 



!, 159, 



355, 350, 302, 303. 
Wood, G. W., 303. 
Wolfe, 3GS. 
Wolff, 302. 

Wollenberg, 57, 255, 362. 
Wyman, 4, GO, 73. 

Young, 359. 

Zanetti, 20. 
Zecchinelli, 371. 
Zeller, 5, 358, 303, 368. 
Zinio, 44. 
Zletarovic, 178. 



27— P. 



INDEX 

Abdominal organs in pellagra, 200. 

Abortion in pellagra, 202. 

Abruzzia, pellagra in, 52, GO. 

Acrodynia differentiated from pellagra, 281. 

Age, influence of, on pellagra, 144. 

Alcoholic Extract of Spoiled Corn, 107. And see Pellagrosine. 

Alcoholism as predisposing to pellagra, 144. 

complicating pellagra, 24G. 

Alkaloid of Spoiled Corn, 115; experiment with, 115. 

Alpine Scurvy, 18. 

Amenorrhea in pellagra, 202. 

Anemia due to spoiled corn, 101; in pellagra, 190. 

Anorexia in pellagra, 152. 

Antizeist School, 121, 130. 

Arsacetin in treatment of pellagra, 309, 310. 

Arsenic in treatment of pellagra, 302, 304, 309, 311, 320. 

Asia Minor, pellagra in, 25. 

Aspergillus glaucus, 85. 

Asturian Leprosy, 18. 

Asturian Rose, 18. 

Astnrias, pellagra in, 27. 

Atavism In pellagra, 353. 

Atoxyl in treatment of pellagra, 309, 310, 311. 

Atrophic pellagra, 183. 

Auch, pellagra in, 30. 

Austria, pellagra in, 61. 

Bacillus tremulus, 86. 
Bacterium maidis, 85, 87, 88, 89. 
Bacterium maidis, experiment with, 95. 
Bacterium mesentericus vulgaris, 85. 
Bacterium thermo, 85. 
"Bald" tongue in pellagra, 153. 
Barbados, pellagra in, 69. 
Bergamo, pellagra in, 50. 



418 PELLAGRA 

Birds, experiments with pellagrosine on, 109. 

Blood, effect of spoiled corn on, 101. 

Blood in pellagra, 190, 205. 

Blood transfusion in treatment of pellagra, 312. 

Bones, fragility of, 270; pathological changes in, 270. 

"Boot" of pellagra, 169, 257. 

Brain, pathological. changes in, 261, 275. 

Brescia, pellagra in, 50. 

Brianza, pellagra in, 37. 

Bulgaria, pellagrins in, 25. 

Cachectic stage of pellagra, 157. 

Cachexia, pellagrous, 148, 149. 

Cairo, pellagra in, 26. 

Campagua, pellagra in, 52. 

Cannes, pellagra in, 185. 

"Cardinal" tongue in pellagra, 153. 

Carolina, North, pellagra in, 72, 73, 74, 76, 168, 170, 172, 

173, 197, 208, 223. 
, South, pellagra in, 72, 73, 76, 168, 169, 170, 172, 173, 

197, 207, 223. 
Casal's "Necklace", 171. 
Cats, experiments with pellagrosine on, 110. 
Cattaneo desiccator, 295. 
Cause of pellagra, theories of, 123. 

unknown, 121. 

Cerebral pellagra, 183. 

Cerebro-spinal symptoms in pellagra, 156. 

Chickens, experiments on, 112. 

Climate as predisposing cause of pellagra, 144. 

Classification of pellagra, 159. 

Clinical study of pellagra, 147. 

Colla, pellagra in, 37. 

Commencing pellagra, 148. 

Communicability of pellagra, 299. 

Complement-fixation tests, 345. 

Complications of pellagra, 144, 246. 

prognostic value of, 286. 

treatment of, 309. 






INDEX 419 

Continued pellagra, 148. 
Constipation in pellagra, 163. 
Contagiousness of pellagra, 299. 
Continuous pellagra, 348. 
Contractures in pellagra, 224. 
Contradictory symptoms in pellagra, 1SS. 
Convulsions, tetanic, in pellagra, 226. 
Corfu, pellagra in, 23. 
Corinthia, pellagra in, 20. 
Corn, as cause of pellagra, 32, 123. 

objections to this theory, 33. 

Corn bread, S3. 

Corn crops in 1907, 402. 

in United States in 1908, 404. 

Corn culture, relation of, to pellagra, 41, 46. 

Corn, damaged, related to pellagra, 47. 

Corn, desiccators for, 295. 

Corn, fat in, 25. 

Corn, foreign, related to pellagra, 46. 

Corn, inspection of, as a prophylactic measure, 293. 

Corn, ordinary, extracts of, 116 ; experiments with, 117. 

Corn, oxidized, oil of, experiments with, 114. 

Corn, relation of, to pellagra, 17 18, 19, 121, 314. 

Corn, sound, oil of, experiments with, 114. 

tincture of, 80. 

Corn, spoiled, a cause of pellagra, 47, 99, 100. 

Corn, spoiled, alcoholic extract of, 82, 107, and see Pella- 

grosine. 
Corn, spoiled, alkaloid of, 115; experiments with, 115. 
Corn, spoiled, aqueous extract of, 82 ; experiments with, 114. 
Corn, spoiled, Aspergillus glaucus in, 85. 
Corn, spoiled, cause of pellagra, 47, 99, 100. 
Corn, spoiled, chemical characters of, 78. 
Corn, spoiled, differentiated from sound corn, 81. 
Corn, spoiled, Eurotinm Jierbariorum in, 85. 
Corn, spoiled, experiments with, on chickens, 23; on dogs, 23. 
Corn, spoiled, extract of embryos of, experiments with, 114. 
Corn, spoiled, glutinous substance of, 82. 
Corn, spoiled, meal of, bacillus tremulus in, 80. 

28— p. 



420 PELLAGRA 

Corn, spoiled, meal of, bacterium maidis in, 85. 

Corn, spoiled, meal of, bacterium thcrmo in, S5. 

Corn, spoiled, microorganisms in, 83, 90. 

Corn, spoiled, moulds on, 91. 

Corn, spoiled, objections to theory of, as cause of pellagra, 33. 

Corn, spoiled, Oidium. lactis maidis in, 84. 

Corn, spoiled, oil extracts from, 111. 

experiments with, on chickens, 112 ; on frogs, 

111 ; on mammals, 113. 
Corn, spoiled, oleoresin of, 82. 
Corn, spoiled, PeniciUum glaucum in, 84. 
Corn, spoiled, physical character of, 77. 
Corn, spoiled, red oil of, 79. 
Corn, spoiled, resinous substance of, 80. 
objection to theory of it being a cause of 

pellagra, 33. 
Corn, spoiled, Sporisorium maidis in, 83. 
Corn, spoiled, Sporothricum maidis in, 85. 
Corn, spoiled, study of, 77. 
Corn, spoiled, tincture of, 79, 104. 

symptoms due to, 104. 

Corn, spoiled, toxic substance of, 80. 

Corn theory of pellagra, objections to, 131. 

Corn, varieties of, cultivated in Italy. 331. 

Country districts only pellagrous, 46. 

"Cravat" in pellagra, 171. 

Cremona, pellagra in, 50. 

Cuba, pellagra in, 74. 

Curative diet, 292. 

Cure of pellagra, Italian law for, 381, 386. 

Dampness and pellagra related, 44. 

Deaths, from pellagra, 59, 240. 

Definition of pellagra, 19. 

Deforestation, a factor in cause of pellagra, 45. 

Dementia, pellagrous, 180. 

Derivation of word pellagra, 20. 

Dermatitis, pellagrous, 163, 165, 168, and see Skin, Eruption, 

Erythema. 
Desiccators for corn, 295. 






IXDEX 421 



Deveaux, apparatus of, 324. 
Development, arrested, in pellagra, 246. 
Diagnosis of pellagra, 251, 278. 
Diarrhea, due to spoiled corn, 102. 

— in pellagra, 1(53. 

Diet, effect of, on pellagra, 315. 

— suitable, prophylactic value of, 341. 
Dietetic treatment of pellagra, 304. 
Differential diagnosis of pellagra, 2S1. 
Digestive symptoms in pellagra, 102. 
Diplodia diseases of corn, 135. 
Disease of the Landes, IS. 

Dogs, experiments on, 110, 115. 
Drowning, in pellagra, 242. 
Drugs in treatment of pellagra, 302, 308. 
"Dry" pellagra, 150. 
Dolce, pellagra in, 37. 
Dyspepsia in pellagra, 1G2. 
Dysphagia in pellagra, 152, 220. 
Dysuria in pellagra, 1SG, 202. 

Early diagnosis of pellagra, 278. 

— value of in pellagra, 285. 

Egypt, pellagra in, 25, 255. 

Electrical reaction of muscles and nerves, 228. 

Emaciation, prognostic value of, 286. 

Emilia, pellagra in, 52, GO. 

Endemic pellagra, 75, 7G. 

Erythema, 257, and see Dermatitis. 

— due to spoiled corn, 102. 

— in pellagra, 154. 

— prognostic value of, 2SG. 
Erythematous stage of pellagra, 140. 
Eruption in pellagra, 154, and see Dermatitis. 

— pellagra with, and without, 148. 
Euphemisms for pellagra, 39. 
Europe, pellagra in. 25. 
Eurothnn herbariorvm, 85. 

Eye symptoms in pellagra, 196. 



422 PELLAGRA 

Face in pellagrous dermatitis, 170. 

"Fagopyrisin" and pellagra, similarity of, 142. 

Farmers' Institutes, 294. 

Fat, percentage of, in corn, 25. 

Feces of pellagrins, 88. 

Feet in pellagrous dermatitis, 169. 

Fever in pellagra, 211. 

— prognostic value of, 285. 

Florid pellagra, 183. 

Forms of pellagra, 159, 182. 

Fowler's Solution in treatment of pellagra, 303. 

France, pellagra in, 28. 

Friuli, pellagra in, 318. 

Frogs, experiments on, 108, 111, 114. 

Gait in pellagra, 156, 229. 

Ganglionic pellagra, 183. 

Gardone, pellagra in, 35. 

Gastralgia in pellagra, 163, 201. 

Gastric juice in pellagra, 163, 201. 

— symptoms in pellagra, 200. 

Gastro-intestinal disturbances in pellagra, 153. 

"Gauntlet" of pellagra, 169, 257. 

Generalizations of pellagra, 182. 

Genito-urinary functions in pellagra, 202. 

Geographical distribution of pellagra, 19, 20, 75. 

"Glove" of pellagra, 169. 

Goitre complicating pellagra, 249. 

Gosio's phenolic reaction, 294. 

Great Britain, pellagra in, 63. 

Greece, pellagra in, 20, 25. 

Gynecological disorders in pellagra, 202. 

Hands in pellagrous dermatitis, 160. 

Harvests, bad, related to pellagra, 45. 

Hashish intoxication complicating pellagra, 259. 

Head in pellagra, 195. 

Heart in pellagra, 191. 

Heart, pathological changes in, 268. 



INDEX 423 

Heat as predisposing cause of pellagra, 143. 

Hereditary pellagra, 37, 251. 

Heredity, effect of, on pellagra, 145. 

History of pellagra, 19. 

Humidity, relation of to pellagra, 33. 

Hydromania in pellagra, 187, 239, 241. 

Hydrotheraphy in treatment of pellagra, 306. 

Ignorance a cause of pellagra, 38. 

Incubation period of pellagra, 151. 

Insane, pellagrous, in Italy, 53, 54, 55, 57. 

Insanity in pellagra, 17(3. 

Insanity, pellagrous, 237, 254, 256, 260. 

Inspection of corn, as a prophylactic measure, 293. 

Intermissions in pellagra, 245. 

Intermittent pellagra, 147. 

Intestinal protozoa in pellagra, 250. 

Intestines, pathological changes in, 269. 

Inverno, pellagra in, 37. 

Ionian Isles, pellagra in, 25. 

Iron in treatment of pellagra, 302. 

Italian law for prevention and cure of pellagra, 3S1, 3S6. 

Italy, deaths from pellagra in, 59. 

Italy, pellagra in, 51, 52, 57, 59, 60, 255. 

— pellagrous insane in, 53, 55, 57. 

Jamaica, pellagra in, 63. 

Kidneys, pathological changes in, 269. 

Landes, the disease of, 18. 

— pellagra in, 1S5. 
La pellarella, 19. 
Lasagna, pellagra in, 185. 

Lathyrism differentiated from pellagra, 281. 

Latium, pellagra in, 52, 60. 

Law, Italian, for prevention and cure of pellagra, 381, 386. 

Lead in treatment of pellagra, 302. 

Leprosy, Asturian, 18. 



424 PELLAGRA 

Leucorrhea in pellagra, 202. 

Liguria, pellagra in, 52, GO. 

Liver, pathological changes in, 2G8. 

Local characteristics of pellagra, 1S3. 

Localization of the dermatitis in pellagra, 1G8. 

Lombardy, pellagra in, 20, 50, 52, GO, 183, 1S4, 249. 

Lungs, pathological changes in, 2G8. 

Maidismus, 18. 

Mai de la Rosa, 18. 

Mai de Misere, 18. 

Mai del Sole, 18. 

Malaria associated with pellagra, 144. 

— complicating pellagra, 250. 
Mammals, experiments on, 113. 
Mantua, pellagra in, 1S4. 

Marasmatic degeneration complicating pellagra, 249. 

Marasmus in pellagra, 158. 

Marches, pellagra in, 52, GO. 

"Mask" of pellagra, 170. 

MeUga, 44. 

Meninges, pathological changes in, 2G1, 2G3. 

Mental phenomena in pellagra, 178. 

prognostic value of, 2SG. 

— symptoms in pellagra, 174, 179. 
Mexico, pellagra in, 28, G9. 
Microorganisms of spoiled corn, 83. 
Milan, pellagra in, 20, 44, 50, 57, 1S4. 
Miraglia Investigation, 48, 49. 
Molise, pellagra in, 52, GO. 
Mombello, pellagrous insane in, 55, 5G. 
Mortality, comparative, of pellagra, 52. 
Motility in pellagra, 223. 

Motor disturbances in pellagra, 156. 

Moulded bread, oil extracted from, experiment with, 113. 

Moulds on spoiled corn, 91. 

Mouth affected in pellagra, 152. 

Mugella, pellagra in, 185. 

Muscles, electrical reaction of, 228. 



INDEX 425 



Muscular force diminished in pellagra, 1SG. 
Muscular spasms due to spoiled com, 102. 

in pellagra, 22G. 

Muscular system, pathological changes in, 270. 
Mutism in pellagra, 25S. 

Nationality, effect of, on pellagra, 145. 
Nerve cells, pathological changes in, 275. 
Nerves, electrical reaction of, 22S. 
Nervous sequels of pellagra, 177. 

— symptoms of pellagra, 174. 

pellagra with, 149. 

Neurasthenia in pellagra, 140, 175. 
Neurasthenic stage of pellagra, 151. 
Noguchi reaction and pellagra, 14G. 
Nutrition, relation of, to pellagra, 47. 

Occupation, effect of, on pellagra, 145. 

Oidium lactis maidis, S4 ; experiments with, 94. 

Oil, red, of spoiled corn, 79. 

Oleoresin of spoiled corn, S2. 

Oospora verticilloides, as cause of pellagra, 11. 

Pain, fleeting, in pellagra, 151. 

— sensibility to, in pellagra, 230. 
Pavia, pellagra in, 1S3, 195. 
Panama, pellngra in, 74. 

Pane giallo, S3. 

Paralytic pellagra, 148. 

Parasitic origin of pellagra, theory of, 13G. 

Paresis, spastic, in pellagra, 224. 

Paresthesia, in pellagra, 157. 

Paretic phenomena, 235. 

Pathological anatomy of pellagra, 2G1. 

Pathology of pellagra, summary of, 271, 272. 

Pau, pellagra in, 30. 

Pavia. pellagra in, 1S3, 1S4, 195. 

Pavy, granary of, 325. 

Pelandria, 1S3. 



426 PELLAGRA 

Pellagra a tropho-neurosis, 149. 

— abdominal organs in, 200. 

— abortion in, 202. 

— alcoholism and, 144, 246. 

— amenorrhea in, 202. 

— an insect-borne disease, 138. 

— an intoxication, 98. 

— and "fagopyrisin," similarity of, 142. 

— anemia in, 190. 

— anorexia in, 152. 

— as a protozoal disease, 132. 

— as an autointoxication, 126. 

— atavism in, 253. 

— atrophic, 183. 

— "bald" tongue in, 153. 

— blood in, 1C0, 205. 

— bones in, 270. 

— "boot" of, 169. 

— brain in, 261, 275. 

— cachectic stage of, 157. 

— cachexia in, 148, 149. 

— "cardinal tongue" in, 153. 

— cause of, theories of, 123. 
unknown, 121. 

— cerebral, 183. 

— cerebro-spinal symptoms in, 156. 

— classification of, 159. 

— clinical study of, 147. 

— commencing, 148. 

— communicability of, 299. 

— comparative mortality of, 52. 

— complement-fixation tests, 145. 

— complications of, 144, 246, 286, 309. 

— confirmed, 148. 

— constipation in, 163. 

— contagiousness of, 299. 

— continuous, 148. 

— contractures in, 224. 

— conveyed by Simulium reptans, 138. 



INDEX 427 



convulsions in, 226. 

course of, 151. 

"cravat" in, 171. 

deaths from, 59, 240. 

definition of, 19. 

degrees of, 14S. 

derivation of name, 20. 

diagnosis of, 251, 278, 285. 

diarrhea in, 163. 

diet, effect of, on, 315. 

differential diagnosis of, 2S1. 

digestive symptoms in, 162. 

diseases associated with, 144. 

disorders of organs of sense in, 157. 

disturbances of sensibility in, 156. 

drowning in, 242. 

"dry," 150. 

due to spoiled corn, 99, 100. 

dyspepsia in, 162. 

dysphagia in, 152, 229. 

dysuria in, 186, 202. 

early diagnosis of, 278, 285. 

endemic, 75, 76. 

eruption in, 14S, 154, and see Dermatitis. 

erythema in, 154, and see Dermatitis. 

erythematous stage of, 149. 

etiology of, 93. 

euphemisms for, 39. 

experimental researches on, 93. 

eye symptoms in, 196. 

fever in, 211, 285. 

first stage of, 153. 

fleeting pains in, 151. 

florid, 183. 

forms of, 159, 182. 

gait in, 156. 

ganglionic, 183. 

gastric symptoms in, 200. 

"gauntlet" of, 169. 



428 



PELLAGRA 



— generalizations of, 1S2. 

— geographical distribution of, 19, 20, 75. 

— "glove" of, 1G0. 

— gynecological disorders in, 202. 

— hereditary, 37, 251. 

— history of, 17, 10. 

— hydromania in, 187, 239, 241. 

— in Austria, Gl. 

— in Barbados, G9. 

— in Cuba, 74. 

— in Great Britain, G3. 

— in Jamaica, G3. 

— in Panama, 74. 

— in Porto Rico, 74. ~ 

— in Roumania, G3. 

— in United States, 70, 7G. 

— in Yucatan, 69. 

— incubation period of, 151. .'. 

— influence of age on, 144. 

climate on, 144. 

nutrition on, 47. 

seasons in, 153. 

— insanity in, 176, 237, 254, 25G, 2G0. 

— intermittent, 147. 

— Italian law for prevention and cure of, 3S1, 3SG. 

— local characteristics of, 1S3. 

— malaria associated with, 144, 250. 

— marasmus in, 15S. 

— "mask" of, 170. 

— mental phenomena of, 178, 2SG. 
symptoms of, 174, 179. 

— mortality from, 52. 

— motor disturbances in, 15G. 

— mouth affected in, 152. 

— mutism in, 258. 

— nationality, effect of, on, 145. 

— "necklace" in, 171. 

— nervous sequels of, 177. 
symptoms of, 174. 



INDEX 429 

— neurasthenia in, 149, 175. 

— neurasthenic stage of, 151. 

— not parasitic, 09. 

— objection to corn theory of, 131. 

— occupation, effect of, on, 145. 

— pains in, 151, 230. 

— paralytic, 14S. 

— parasitic origin of, theory of, 13G. 

— paresthesia in, 157. 

— pathogenesis of, 141. 

— pathology of, 2G1, 271, 272. 

— predisposing causes of, 143. 

— pre-erythematous stage of, 149. 

— prodromal stage of, 149, 151. 

— prognosis of, 283. 

— prophylaxis of, 287, 314, 321, 399. 

— psychic pheuomena in, 149, 1S7, 235, 23S, 245. 

— reflexes in, 192, 227. 

— relation of humidity to, 33. 
of. to corn, 19, 121, 314. 

— remittent, 14S. 

— second stage of, 15G. 

— signs of, 1S2. 

— sine pellagra, 14S, 159, ICO, 1G2, 172, 252, 2S0. 

— sites of dermatitis in, 1GS. 

— skin manifestations in, 154, and see Dermatitis. 

— spasmodic, 14S. 

— "spells", 22G. 

— spinal, 1S3. 

disturbances in, 179. 

— sporadic, 7G. 

— stages of, 149. 

— statistics of, 44, 50, 55. 5S, GO, 255. 

— stomach affected in, 152. 

— stomatitis in, 152. 

— suicides in, 243. 

— symptoms of, 182. 

— synonyms of, 18. 

— syphilis in, 24S, 259. 



430 PELLAGRA 

— temperature in, 160, 211. 

— tendon reflexes in, 157. 

— tetanic, 183. 

— third stage of, 157. 

— tongue in, 153. 

— transfusion of blood in, treatment of, 312. 

— treatment of, 300, 314, 326. 

— types of, 147, 148. 

— typhoid, 56, 159, 160, 161, 181, 191, 218, 226, 274, 281, 

282, 289. 

— wine in, 186, 190, 202, 215. 

— varieties of, 182. 

— "Verderame" theory of, 122. 

— "wet," 150. 

— with, and without, eruption, 148. 

— with nervous symptoms, 149. 

— with psychic symptoms, 149. 

— "Zeist" and "Antizeist" schools, 121. 
Pellagrosine, 80, 81, 107. 

Pellagrosine, experiments with, on birds, 109; on cats, 110; 
on dogs, 110 ; on frogs, 108 ; on rodents, 109. 

— symptoms due to, 107. 
Pellagrosari, 293. 
Pellagrous cachexia, 148, 149. 

— dementia, 180. 

— dermatitis, 163, 165, and see Skin, Eruption, Erythema. 
method of healing, 172. 

— insane in Italy, 53, 55, 57. 

— insanity, 237, 254, 256, 260. 

— pseudo-paresis, 239. 
Pellarella, la, 19. 
Penicillium glaucum, 83. 
as cause of pellagra, 22. 

— maidis, as cause of pellagra, 23. 
Perugia, pellagra in, 45, 46. 
Photophobia, 243. 

Piatra, pellagra in, 22. 
Piedmont, pellagra in, 52, 60. 
Pieve, pellagra in, 35. 



INDEX 431 



Polenta, 34. 

Porto Rico, pellagra in, 74. 

Poverty, a cause of pellagra, 34. 

Precipitine test, 279. 

Pre-erytheinatous stage of pellagra, 149. 

Prevention of pellagra, Italian law for, 3S1, 386. 

Pro-dronial stage of pellagra, 149, 151. 

Prognosis, 2S3. 

Prophylaxis of pellagra, 2S7, 314, 321, 399. 

Protozoa, intestinal, complicating pellagra, 250. 

Pseudo-paresis, pellagrous, 239. 

Pseudopellagra, 131. 

Psychic disorders in pellagra, 187. 

— phenomena in pellagra, 235. 

— symptoms, 235, 238. 

intermissions in, 245. 

pellagra with, 149. 

Psychoneurosis Maidica, 18. 

Puccinia nigricans, as cause of pellagra, 22. 

— segctvm, as cause of pellagra, 22. 
Pulse, effect of spoiled corn on, 101. 
Pyrosis, in pellagra, 152. 

Reaction, electrical, of muscles and nerves, 228. 

Reflex uterine troubles in pellagra, 191. 

Reflexes in pellagra, 192, 227. 

Reggio, pellagra in, 184. 

Remittent pellagra, 148. 

Respiration, effect of spoiled corn on, 101. 

Rivoli, pellagra in, 37. 

Rodents, experiments with pellagrosine on, 109. 

Romagna, pellagra in, 185. 

Rose, Asturian, 18. 

Roumania, pellagra in, 22, G3, 248. 

— pellagrins in, 25. 

Saliva, condition of, in pellagra, 152. 

Salso, 183. 

Salt, and see Sodium Chloride. 



432 PELLAGRA 

— as a prophylactic, 291. 

— bath or rub, in treatment of pellagra, 307. 
Schiovatrio, 35. 

Scurvy, Alpiue, 18. 

Season, as predisposing cause of pellagra, 143. 

— influence of, on pellagra, 103. 
Seasonal incidence of pellagra, 153. 
Second stage of pellagra, 156. 
Sensation, anomalies of, in pellagra, 233. 
Sense, disorders of organs of, in pellagra, 157. 
Sensibility, disorders of, in pellagra, 1S7. 

— disturbances of, in pellagra, 15G. 

— general, in pellagra, 223. 

— to pain, in pellagra, 230. 

— to touch, in pellagra, 230. 
Sermide, pellagra in, 37, 49. 
Serum treatment of pellagra, 312. 
Servia, pellagrins in, 25. 

Sex, influence of, on pellagra, 144. 

Sexual organs, pathological changes in, 270. 

Signs of pellagra, 182. 

SimuUum reptans, believed to convey pellagra, 138. 

Sitomania, 259. 

Sitophobia, in pellagra, 1S7, 200, 240, 259. 

Skeleton, pathological changes in, 270. 

Skin, affected by spoiled corn, 102. 

— in pellagra, 1SG, 193. 

— manifestations in pellagra, 154, and see Dermatitis. 

— pathological changes in, 270. 

— symptoms, value of, in diagnosis, 2S0. 
Smell, sense of, in pellagra, 232. 

Soamin, in treatment of pellagra, 309, 310, 311. 
Sodium arsanilate, in treatment of pellagra, 309. 
Sodium chloride, 291, and see Salt. 

in treatment of pellagra, 302, 304, 326. 

Sondrio, pellagra in, 44. 

Spain, pellagra in, 27, 185. 

Spasmodic pellagra, 148. 

Spasms, muscular, due to spoiled corn, 102. 



INDEX 433 



in pellagra, 22G. 

Spastic paresis, in pellagra, 224. 

Special sense, organs of, in pellagra, 195. 

"Spells, pellagra," 22G. 

Spinal cord, pathological changes in, 2G3, 27G. 

Spinal disturbances in pellagra, 179. 

— pellagra, 1S3. 

Spleen, pathological changes in, 2G9. 

Sporadic pellagra, 7G. 

Sporisorium mahlis, S3. 

Sporothricum maidis. S5. 

Stages of pellagra, 149. 

Statistics, 44, 50, 55, 58, GO, 255. 

Stomach affected in pellagra, 152. 

Stomatitis in pellagra, 152. 

Straehan's disease, Go. 

Suicides in pellagra, 243. 

Sun as predisposing to pellagra, 143. 

Sympathetic nervous system in pellagra, 101. 

Symptoms of pellagra, 1S2. 

Synonyms of pellagra, 18. 

Syphilis complicating pellagra, 248, 259. 

Taste, sense of, in pellagra, 232. 
Temperature, effect of spoiled corn on, 101. 

— in pellagra, 1G0, 211. 
Tendinous phenomena in pellagra, 227. 
Tendon reflexes in pellagra, 157. 
Tetanic convulsions in pellagra, 22G. 

— pellagra, 1S3. 
Tessin, pellagra in, 20. 

Thermic phenomena in pellagra, 211. 
Third stage of pellagra, 157. 
Thoracic organs, in pellagra, 200. 
Thyroid disease complicating pellagra, 249. 
Tincture of sound corn, SO. 

spoiled corn, 79, 104. 

Touch, sensibility to, in pellagra, 230. 
Treatment of pellagra, 300. 314. 
early, advocated, 32G. 



I 

434 PELLAGRA 

Tremor in pellagra, 224. 

Treviso, pellagra in, 20. 

Trieste, pellagra in, 184. 

Tripoli, pellagra in, 25. 

Tuberculosis complicating pellagra, 248. 

Tunis, pellagra in, 25. 

Turkey, pellagra in, 25. 

Tuscany, pellagra in, 52, 60, 184, 185, 195. 

Typhoid pellagra, 50, 159, 160, 161, 181, 191, 218, 226, 274, 

281, 282, 289. 
Typhus pellagrosus, 160. 
Tyrol, pellagra in, 183, 184, 195, 248. 

Udine, pellagra in, 44. 

Umbria, pellagra in, 45, 52, 60. 

United States, pellagra in, 41, 70, 76. 

Urinary disturbances in pellagra, 186. 

Urine, condition of, in pellagra, 186, 190, 202, 215. 

Uterine complications of pellagra, 249. 

— disorders in pellagra, 202. 

— troubles, reflex, in pellagra, 191. 

Vanity, a cause of pellagra, 39. 

Varieties of pellagra, 182. 

Venice, pellagra in, 20, 33, 51, 60, 183, 195. 

Verderame, 327. 

"Verderame" theory of pellagra, 122, 327. 

Verona, pellagra in, 183. 

Vision, sense of, in pellagra, 232. 

Wassermann reaction and pellagra, 145. 

Weakness in pellagra, 152. 

Weight, effect of spoiled corn on, 101. 

— in pellagra, 192. 
"Wet" pellagra, 150. 

Yucatan, pellagra in, 69. 

"Zeist" and "Antizeist" schools, 121. 
Zeitoxic School, 122, 131. 






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